Provider Demographics
NPI:1669413126
Name:WILLIS-BUCKLEY, TAMARA L (MD)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:L
Last Name:WILLIS-BUCKLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:L
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2700 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-8473
Mailing Address - Country:US
Mailing Address - Phone:970-581-0119
Mailing Address - Fax:
Practice Address - Street 1:1701 W 72ND AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80221-2721
Practice Address - Country:US
Practice Address - Phone:303-650-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-13841207V00000X
CO44373207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO018888OtherKAISER COMMERCIAL NUMBER
HI0000260901OtherHMSA BILLING NUMBER
CO23825545Medicaid
HIH101593Medicare PIN
COCO300546Medicare PIN
CO018888OtherKAISER COMMERCIAL NUMBER
COCOA105395Medicare PIN
HI0000260901OtherHMSA BILLING NUMBER