Provider Demographics
NPI:1225094659
Name:BUCKLEY, KAREN M (MD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:M
Last Name:BUCKLEY
Suffix:
Gender:F
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:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7901 S 12TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3831
Practice Address - Country:US
Practice Address - Phone:269-372-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA066391002086S0122X
NC2009-017352086S0122X
NY21702612086S0122X
MI4301505730208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02131235170Medicaid
NC5913510Medicaid
NC155UHOtherBCBSNC
NC2075380Medicare PIN
NYH14505Medicare UPIN
NC5913510Medicaid