Provider Demographics
NPI:1134104466
Name:BUCKLEY, BRENDA LYNN (MD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1747 SMIZER STATION RD,
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2124
Mailing Address - Country:US
Mailing Address - Phone:636-529-7000
Mailing Address - Fax:636-529-7003
Practice Address - Street 1:1747 SMIZER STATION RD
Practice Address - Street 2:SUITE 5
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2784
Practice Address - Country:US
Practice Address - Phone:636-529-7000
Practice Address - Fax:636-529-7003
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2016-02-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO115447207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1134104466Medicaid
MO1134104466Medicaid
MO000095305Medicare ID - Type Unspecified
MOH78978Medicare UPIN
MO205692908Medicare ID - Type Unspecified