Basic Information
| Provider Information | |||||||||
| NPI: | 1255384111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKSTEIN | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5177 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850105177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023445651 | ||||||||
| FaxNumber: | 6023445578 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 E ROOSEVELT ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850084948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023445651 | ||||||||
| FaxNumber: | 6023445578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 07/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 14781 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 278730 | 05 | AS | MEDICAID |