Provider Demographics
NPI:1578583183
Name:BUCKINGHAM, MARK C (MSPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:C
Last Name:BUCKINGHAM
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15415 NEWTON DR
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-2847
Mailing Address - Country:US
Mailing Address - Phone:913-706-6564
Mailing Address - Fax:
Practice Address - Street 1:11408 W 135TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66221-9398
Practice Address - Country:US
Practice Address - Phone:913-681-9909
Practice Address - Fax:913-681-9906
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS31489OtherFREEDOM NETWORK
KS31489037OtherBCBS
KS31489OtherPHP
KS31489OtherPHP