Provider Demographics
NPI:1023084159
Name:BUXBAUM, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BUXBAUM
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:P O BOX 42
Mailing Address - Street 2:
Mailing Address - City:GWYNEDD
Mailing Address - State:PA
Mailing Address - Zip Code:19436-0042
Mailing Address - Country:US
Mailing Address - Phone:215-442-5500
Mailing Address - Fax:215-442-1641
Practice Address - Street 1:116 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19459
Practice Address - Country:US
Practice Address - Phone:215-699-1206
Practice Address - Fax:215-699-1206
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039175L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104436OtherBLUE SHIELD
PA0040523000OtherKEYSTONE
PA000991520006Medicaid
PA104436OtherBLUE SHIELD
PA0040523000OtherKEYSTONE