Healthcare Provider Details

I. General information

NPI: 1154470458
Provider Name (Legal Business Name): MARY GORDON BUCKINGHAM BROWN NPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 BREMO ROAD SUITE 501
RICHMOND VA
23226
US

IV. Provider business mailing address

PO BOX 247
MIDLOTHIAN VA
23113
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-9899
  • Fax: 804-282-2619
Mailing address:
  • Phone: 804-378-5010
  • Fax: 804-378-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0024167127
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: