Provider Demographics
NPI:1992778468
Name:BUCKINGHAM, MAURA E (DO)
Entity type:Individual
Prefix:DR
First Name:MAURA
Middle Name:E
Last Name:BUCKINGHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MAURA
Other - Middle Name:E
Other - Last Name:KACZKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:955 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-6743
Mailing Address - Country:US
Mailing Address - Phone:269-639-2893
Mailing Address - Fax:269-693-2894
Practice Address - Street 1:955 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-6743
Practice Address - Country:US
Practice Address - Phone:269-639-2893
Practice Address - Fax:269-693-2894
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011483208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4579104Medicaid
MI0N87470Medicare ID - Type Unspecified
MI4579104Medicaid