Provider Demographics
NPI:1063594778
Name:BUCKENBERGER, ROBERT KENDALL (DPM)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:KENDALL
Last Name:BUCKENBERGER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 E HERNDON AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3377
Mailing Address - Country:US
Mailing Address - Phone:559-439-8642
Mailing Address - Fax:559-433-9834
Practice Address - Street 1:1642 E HERNDON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3377
Practice Address - Country:US
Practice Address - Phone:559-439-8642
Practice Address - Fax:559-433-9834
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3931213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E39310Medicaid
U49729Medicare UPIN
CA4673360001Medicare NSC
CA000E39310Medicaid