Provider Demographics
NPI:1912060179
Name:BUCKLEY, JOHN WILLIAM JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:BUCKLEY
Suffix:JR
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 1:5220 LONG GREEN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ARM
Mailing Address - State:MD
Mailing Address - Zip Code:21057-9716
Mailing Address - Country:US
Mailing Address - Phone:410-592-5955
Mailing Address - Fax:
Practice Address - Street 1:5220 LONG GREEN RD
Practice Address - Street 2:
Practice Address - City:GLEN ARM
Practice Address - State:MD
Practice Address - Zip Code:21057-9716
Practice Address - Country:US
Practice Address - Phone:410-592-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00133642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD77666Medicare UPIN
MD1945Medicare ID - Type Unspecified