Provider Demographics
NPI:1477205359
Name:BUCKELEW, JOHN WILLIAM JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:BUCKELEW
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3133 DENTON PL NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-6124
Mailing Address - Country:US
Mailing Address - Phone:404-229-1132
Mailing Address - Fax:470-375-3705
Practice Address - Street 1:3133 DENTON PL NE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-6124
Practice Address - Country:US
Practice Address - Phone:404-229-1132
Practice Address - Fax:470-375-3705
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA976747440-00OtherUNITED HEALTHCARE