Provider Demographics
NPI:1962620666
Name:BUCKHOUT, BRADLEY C (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:C
Last Name:BUCKHOUT
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 1:650 E INDIAN SCHOOL RD
Mailing Address - Street 2:CLC
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1839
Mailing Address - Country:US
Mailing Address - Phone:602-277-5551
Mailing Address - Fax:602-200-6039
Practice Address - Street 1:650 E INDIAN SCHOOL RD
Practice Address - Street 2:CLC
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:602-277-5551
Practice Address - Fax:602-200-6039
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-01-08
Deactivation Date:2006-10-25
Deactivation Code:
Reactivation Date:2007-04-20
Provider Licenses
StateLicense IDTaxonomies
AZ13405207Q00000X, 207QG0300X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD36707Medicare UPIN