Basic Information
| Provider Information | |||||||||
| NPI: | 1134128051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKLEY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 BERWYN HOUSE RD | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207402474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012200150 | ||||||||
| FaxNumber: | 3012201032 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 BERWYN HOUSE RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207402474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013450406 | ||||||||
| FaxNumber: | 3013450409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | D16341 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085N0904X | MD25540 | DC | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085N0904X | 019671 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0430630 | 05 | DC | MEDICAID |