Provider Demographics
NPI:1043607542
Name:BUCKLEY, MARY MCGOWAN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MCGOWAN
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CLAIRE
Other - Last Name:MCGOWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN ROAD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-014272080P0216X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program