Basic Information
| Provider Information | |||||||||
| NPI: | 1174733083 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DUSTAN P BUCKLEY MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3967 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730833967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057497030 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Practice Location | |||||||||
| Address1: | 4140 W MEMORIAL RD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057497030 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | BUCKLEY | ||||||||
| AuthorizedOfficialFirstName: | DUSTAN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4057497030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 18504 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100228630A | 05 | OK | MEDICAID |