Provider Demographics
NPI:1548206360
Name:BUCKNAM, WILLIAM CARLIN (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CARLIN
Last Name:BUCKNAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:C
Other - Last Name:BUCKNAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PC
Mailing Address - Street 1:202 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1507
Mailing Address - Country:US
Mailing Address - Phone:608-417-6000
Mailing Address - Fax:
Practice Address - Street 1:1018 GAMMON LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2256
Practice Address - Country:US
Practice Address - Phone:608-417-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0431672084A0401X, 2084P0800X
WI542982084P0800X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1674010Medicaid
MI1674010Medicaid
0810896Medicare ID - Type Unspecified