Provider Demographics
NPI:1376544668
Name:BUCKLEY, NIALL J (MD)
Entity Type:Individual
Prefix:MR
First Name:NIALL
Middle Name:J
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 FRASIER ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2125
Mailing Address - Country:US
Mailing Address - Phone:919-477-7003
Mailing Address - Fax:919-471-2827
Practice Address - Street 1:205 FRASIER ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2125
Practice Address - Country:US
Practice Address - Phone:919-477-7003
Practice Address - Fax:919-471-2827
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00 40028208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7919451Medicaid
2158347Medicare ID - Type Unspecified
E76867Medicare UPIN