Provider Demographics
NPI:1174733083
Name:DUSTAN P BUCKLEY MD PC
Entity type:Organization
Organization Name:DUSTAN P BUCKLEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DUSTAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-749-7030
Mailing Address - Street 1:PO BOX 3967
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-3967
Mailing Address - Country:US
Mailing Address - Phone:405-749-7030
Mailing Address - Fax:405-292-5505
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:SUITE 303
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8366
Practice Address - Country:US
Practice Address - Phone:405-749-7030
Practice Address - Fax:405-292-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18504207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100228630AMedicaid
OK100228630AMedicaid
OKG34356Medicare UPIN