Basic Information
Provider Information | |||||||||
NPI: | 1467434142 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUCKINGHAM | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 128 | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787670128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124012500 | ||||||||
FaxNumber: | 5124012501 | ||||||||
Practice Location | |||||||||
Address1: | 2745 BEE CAVES ROAD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 78746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124012500 | ||||||||
FaxNumber: | 5124012501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2005 | ||||||||
LastUpdateDate: | 11/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0123X | K5468 | TX | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery |
ID Information
ID | Type | State | Issuer | Description | 144634100 | 01 |   | FIRST CARE | OTHER | 8V2550 | 01 | TX | BCBS | OTHER | 276816 | 01 |   | AMERIGROUP | OTHER | 163600302 | 05 | TX |   | MEDICAID |