Provider Demographics
NPI:1134118185
Name:BUCON, KIRK A (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:A
Last Name:BUCON
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 1:5322 W NORTHERN AVE
Mailing Address - Street 2:SOUTHWEST DIAGNOSTIC IMAGING LTD
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-1405
Mailing Address - Country:US
Mailing Address - Phone:480-425-5063
Mailing Address - Fax:623-915-6924
Practice Address - Street 1:5322 W NORTHERN AVE
Practice Address - Street 2:SOUTHWEST DIAGNOSTIC IMAGING LTD
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1405
Practice Address - Country:US
Practice Address - Phone:480-425-5063
Practice Address - Fax:623-915-6924
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ161512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ254285Medicaid
AZ30WCFHS02OtherVRL
AZ30WCFHS02OtherVRL
AZ254285Medicaid