Provider Demographics
NPI:1508143694
Name:BUCKLEY, GARY DOUGLAS JR (PT,,DPT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DOUGLAS
Last Name:BUCKLEY
Suffix:JR
Gender:M
Credentials:PT,,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CRESTWOOD CIR STE G
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-5512
Mailing Address - Country:US
Mailing Address - Phone:479-394-1161
Mailing Address - Fax:479-394-7667
Practice Address - Street 1:400 CRESTWOOD CIR STE G
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-5512
Practice Address - Country:US
Practice Address - Phone:479-394-1161
Practice Address - Fax:479-394-7667
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3411225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist