Provider Demographics
NPI:1831252915
Name:BUCKWALTER, JEFFREY ALLEN (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
Last Name:BUCKWALTER
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 1:2100 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-1052
Mailing Address - Country:US
Mailing Address - Phone:215-368-5290
Mailing Address - Fax:215-348-7416
Practice Address - Street 1:2100 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-1052
Practice Address - Country:US
Practice Address - Phone:215-368-5290
Practice Address - Fax:215-368-4401
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030903E207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABU090606Medicare ID - Type Unspecified
B35460Medicare UPIN