Provider Demographics
NPI:1821417635
Name:BUCKINGHAM, EVAN BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:BRYAN
Last Name:BUCKINGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 5TH AVE APT 18E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3131
Mailing Address - Country:US
Mailing Address - Phone:443-845-3665
Mailing Address - Fax:
Practice Address - Street 1:1100 FRANKLIN AVE STE 203
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1601
Practice Address - Country:US
Practice Address - Phone:516-248-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY318707208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program