Provider Demographics
NPI:1093938359
Name:BUCKMAN, LAWRENCE EDWARD III (C PED)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:EDWARD
Last Name:BUCKMAN
Suffix:III
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5823 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4963
Mailing Address - Country:US
Mailing Address - Phone:815-654-1900
Mailing Address - Fax:815-282-9567
Practice Address - Street 1:5823 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4963
Practice Address - Country:US
Practice Address - Phone:815-654-1900
Practice Address - Fax:815-282-9567
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies