Provider Demographics
NPI:1134128051
Name:BUCKLEY, CHARLES EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:BUCKLEY
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 1:4700 BERWYN HOUSE RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2474
Mailing Address - Country:US
Mailing Address - Phone:301-220-0150
Mailing Address - Fax:301-220-1032
Practice Address - Street 1:4700 BERWYN HOUSE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2474
Practice Address - Country:US
Practice Address - Phone:301-345-0406
Practice Address - Fax:301-345-0409
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD163412085N0904X
DCMD255402085N0904X
VA0196712085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0430630Medicaid
DC0430630Medicaid
C88769Medicare UPIN