Provider Demographics
NPI:1568431625
Name:BUCKNER, CARY D
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:D
Last Name:BUCKNER
Suffix:
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:PO BOX 7490
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702
Mailing Address - Country:US
Mailing Address - Phone:718-246-8614
Mailing Address - Fax:718-246-8656
Practice Address - Street 1:263 7TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215
Practice Address - Country:US
Practice Address - Phone:718-246-8614
Practice Address - Fax:718-246-8656
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY498802084N0400X
NY2029742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01952221Medicaid
IN300002093Medicaid
KY7100484770Medicaid
KY7100484770Medicaid
NY17B671Medicare PIN