Provider Demographics
NPI:1740283126
Name:BUCKLEY, STEPHEN E (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
Last Name:BUCKLEY
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 1:100 METHODIST HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1295
Mailing Address - Country:US
Mailing Address - Phone:601-268-5185
Mailing Address - Fax:601-268-5006
Practice Address - Street 1:100 METHODIST HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1295
Practice Address - Country:US
Practice Address - Phone:601-268-5185
Practice Address - Fax:601-268-5006
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12824207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00011825Medicaid
MSE99729Medicare UPIN