Provider Demographics
NPI:1164415857
Name:BUCKINGHAM, CHARLES G (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:BUCKINGHAM
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 1:300 N HIGHLAND AVE STE 415
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-7390
Mailing Address - Country:US
Mailing Address - Phone:903-892-8111
Mailing Address - Fax:903-893-8437
Practice Address - Street 1:300 N HIGHLAND AVE STE 415
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7390
Practice Address - Country:US
Practice Address - Phone:903-892-8111
Practice Address - Fax:903-893-8437
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD0814174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110133904Medicaid
TXB21547Medicare UPIN
TXTXB139846Medicare PIN
TX8B8744Medicare ID - Type Unspecified
TXTXB139854Medicare PIN
TX110133904Medicaid