Provider Demographics
NPI:1831283597
Name:BUCKLEY, THERESA M (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:BUCKLEY
Suffix:
Gender:F
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:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:503-261-4475
Mailing Address - Fax:503-261-4476
Practice Address - Street 1:10201 SE MAIN ST STE 29
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2937
Practice Address - Country:US
Practice Address - Phone:503-261-4475
Practice Address - Fax:503-261-4476
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD280082084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR007192Medicaid
CA00A679360Medicaid
CAH68521Medicare UPIN
CA00A679361Medicare PIN
OR007192Medicaid