Provider Demographics
NPI:1558466516
Name:BUCKALOO, JERROLD M (MD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:M
Last Name:BUCKALOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1175 COOK RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8201
Mailing Address - Country:US
Mailing Address - Phone:803-395-3837
Mailing Address - Fax:803-536-5122
Practice Address - Street 1:1175 COOK RD
Practice Address - Street 2:SUITE 215
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-395-3837
Practice Address - Fax:803-536-5122
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-02-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC20903207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00727280OtherRAILROAD MEDICARE ID-RSFPN
SC209036Medicaid
SCP00401081OtherRAILROAD MEDICARE ID
SCG58766Medicare UPIN