Provider Demographics
NPI:1265402846
Name:BUCKAU, JEFFREY ALLEN (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALLEN
Last Name:BUCKAU
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:3625 5TH ST STE 202
Mailing Address - Street 2:MOUNTAINSIDE FAMILY PRACTICE
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6002
Mailing Address - Country:US
Mailing Address - Phone:605-348-2636
Mailing Address - Fax:605-716-0172
Practice Address - Street 1:3625 5TH ST STE 202
Practice Address - Street 2:MOUNTAINSIDE FAMILY PRACTICE
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6002
Practice Address - Country:US
Practice Address - Phone:605-348-2636
Practice Address - Fax:605-716-0172
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SD5034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5601743Medicaid
SD5601742Medicaid
SD5601742Medicaid
SDS41170Medicare ID - Type UnspecifiedMEDICARE