Provider Demographics
NPI:1295722635
Name:BUCKINGHAM, HEIDI (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:BUCKINGHAM
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 1:3170 KETTERING BLVD BLDG B
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:400 SUGAR CAMP CIR STE 205
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:OH
Practice Address - Zip Code:45409-1981
Practice Address - Country:US
Practice Address - Phone:937-395-3656
Practice Address - Fax:937-395-3657
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024501207RE0101X
OH35.089021207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2754845Medicaid
OH4219401Medicare PIN
OH4219402Medicare PIN