Provider Demographics
NPI:1336133495
Name:BUCKSPAN, RANDY J (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:J
Last Name:BUCKSPAN
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 1:9115 KATE CT
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-3960
Mailing Address - Country:US
Mailing Address - Phone:512-924-8126
Mailing Address - Fax:
Practice Address - Street 1:9115 KATE CT
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-3960
Practice Address - Country:US
Practice Address - Phone:512-924-8126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA90826208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA98760Medicare UPIN