Provider Demographics
NPI:1215997697
Name:BUCKSBAUM, MARK JAY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JAY
Last Name:BUCKSBAUM
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 1:69 ALLEN ST
Mailing Address - Street 2:STE 9
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4564
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:69 ALLEN ST
Practice Address - Street 2:STE 9
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4564
Practice Address - Country:US
Practice Address - Phone:417-875-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420007956208100000X
MO20160227512081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009492Medicaid
MO1215997697Medicaid
VTVT9492Medicare PIN
MO1215997697Medicaid