Provider Demographics
NPI:1093019119
Name:W. BRUCE BUCKLEW, MD, PLLC
Entity Type:Organization
Organization Name:W. BRUCE BUCKLEW, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-409-3445
Mailing Address - Street 1:5860 S HOSPITAL DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-9449
Mailing Address - Country:US
Mailing Address - Phone:928-402-1168
Mailing Address - Fax:928-402-1119
Practice Address - Street 1:5860 S HOSPITAL DR
Practice Address - Street 2:SUITE 106
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9449
Practice Address - Country:US
Practice Address - Phone:928-402-1168
Practice Address - Fax:928-402-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty