Healthcare Provider Details

I. General information

NPI: 1548206360
Provider Name (Legal Business Name): WILLIAM CARLIN BUCKNAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WILLIAM C BUCKNAM MD PC

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 GAMMON LN
MADISON WI
53719-2256
US

IV. Provider business mailing address

202 S PARK ST
MADISON WI
53715-1507
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-8144
  • Fax:
Mailing address:
  • Phone: 608-417-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number043167
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number043167
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number54298
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number54298
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: