Basic Information
| Provider Information | |||||||||
| NPI: | 1730171794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKLEY | ||||||||
| FirstName: | DUSTAN | ||||||||
| MiddleName: | PIERCE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9100 N MAY AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731204417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058404456 | ||||||||
| FaxNumber: | 4058404295 | ||||||||
| Practice Location | |||||||||
| Address1: | 9100 N MAY AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058404456 | ||||||||
| FaxNumber: | 4058404295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 18504 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100228630A | 05 | OK | MEDICAID | 110224377 | 01 | OK | RAILROAD MEDICARE | OTHER |