Provider Demographics
NPI:1619082351
Name:BUCKINGHAM, ULISA DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:ULISA
Middle Name:DIANE
Last Name:BUCKINGHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:U.
Other - Middle Name:DIANE
Other - Last Name:BUCKINGHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 25173
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66225-5173
Mailing Address - Country:US
Mailing Address - Phone:913-791-1292
Mailing Address - Fax:913-469-6440
Practice Address - Street 1:200 MAINE ST
Practice Address - Street 2:BERT NASH
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1368
Practice Address - Country:US
Practice Address - Phone:785-843-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-233122084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS20-2932962OtherFEDERAL TAX ID