Provider Demographics
NPI:1114918133
Name:BUCKLEY, JOHN JOSEPH JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:BUCKLEY
Suffix:JR
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 1:33 WILDFERN DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1661
Mailing Address - Country:US
Mailing Address - Phone:330-759-2048
Mailing Address - Fax:
Practice Address - Street 1:935 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5062
Practice Address - Country:US
Practice Address - Phone:330-758-8146
Practice Address - Fax:330-758-1399
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3504815113174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0631169Medicaid
OH0631169Medicaid
OH0586981Medicare PIN