Provider Demographics
NPI:1942407283
Name:PARK AVENUE WALK IN CLINIC
Entity type:Organization
Organization Name:PARK AVENUE WALK IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-825-8181
Mailing Address - Street 1:1280 MONUMENT BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4405
Mailing Address - Country:US
Mailing Address - Phone:925-825-8181
Mailing Address - Fax:925-825-8383
Practice Address - Street 1:1280 MONUMENT BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4405
Practice Address - Country:US
Practice Address - Phone:925-825-8181
Practice Address - Fax:925-825-8383
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BUCKWALTER FAMILY MEDICINE LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-29
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003813478OtherNPI INDIVIDUAL
CA1942407283OtherNPI TYPE 2
CA1942407283OtherNPI TYPE 2
CA00A847201Medicare PIN