Provider Demographics
NPI:1093877292
Name:BUCKLEN, KEITH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:R
Last Name:BUCKLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7951 GLEN ABBY CIR
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28164-7402
Mailing Address - Country:US
Mailing Address - Phone:704-827-2825
Mailing Address - Fax:704-827-2825
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501383208600000X
NC2005-01383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC140UUOtherBCBS GROUP NUMBER
NC5901752Medicaid
NC140UUOtherBCBS GROUP NUMBER
NC2046927Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE
NC2046927BMedicare PIN
NC2348555Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER