Provider Demographics
NPI:1881671626
Name:BUCKSON, THERESA A (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:BUCKSON
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 1:777 LOWNDES HILL RD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2101
Mailing Address - Country:US
Mailing Address - Phone:864-908-3530
Mailing Address - Fax:864-627-9920
Practice Address - Street 1:6200 SW 73RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4679
Practice Address - Country:US
Practice Address - Phone:786-662-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056988207V00000X
FLME140849207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD693501000Medicaid
MDH50160Medicare UPIN