Provider Demographics
NPI:1659359891
Name:BUCKLEY, ALICE (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1297 NEVADA HWY STE A
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-1854
Mailing Address - Country:US
Mailing Address - Phone:702-294-1919
Mailing Address - Fax:702-294-0072
Practice Address - Street 1:285 W 12TH ST STE 206
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1654
Practice Address - Country:US
Practice Address - Phone:765-475-8510
Practice Address - Fax:765-475-8512
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4648207R00000X
NV12830207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F91929Medicare UPIN