Provider Demographics
NPI:1629308762
Name:BUCKNER, MARTIN WILLIAM (CPO)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:WILLIAM
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE # 46
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-6210
Mailing Address - Fax:312-227-9429
Practice Address - Street 1:225 E CHICAGO AVE # 46
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-6210
Practice Address - Fax:312-227-9429
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL211.000186174400000X
IL213.000220174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist