Provider Demographics
NPI:1386716421
Name:BUCKO, CARROLL DENNIS (M D)
Entity type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:DENNIS
Last Name:BUCKO
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9900 GENESEE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1210
Mailing Address - Country:US
Mailing Address - Phone:858-453-8484
Mailing Address - Fax:858-453-3284
Practice Address - Street 1:9900 GENESEE AVE STE B
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1210
Practice Address - Country:US
Practice Address - Phone:858-453-8484
Practice Address - Fax:858-453-3284
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44143208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A92469Medicare UPIN