MEDICARE: GERALD BUCKBERG M.D. INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service	G11527	CA

General Provider Information

NPI Number	:	1982032603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERALD BUCKBERG M.D. INC

Provider Business Mailing Address
First Line	:	UCLA MEDICAL CTR
Second Line	:	10833 LE CONTE AVENUE 62-258 CHS
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1741
Country	:	US
Telephone Number	:	310-206-1027
Fax Number	:

Provider Business Practice Location Address
First Line	:	UCLA MEDICAL CTR
Second Line	:	10833 LE CONTE AVENUE 62-258 CHS
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1741
Country	:	US
Telephone Number	:	310-206-1027
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GERALD DAVID BUCKBERG
Credential	:	M.D.
Telephone Number	:	310-206-1027

Provider Enumeration Date	:	10/15/2013
Last Update Date	:	10/15/2013

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