Provider Demographics
NPI:1447301700
Name:BUCK, ANDREA SUE (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:SUE
Last Name:BUCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:103 OLD MARLTON PIKE
Mailing Address - Street 2:SUITE 215 MEDFORD MEDICAL BUILDING
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8772
Mailing Address - Country:US
Mailing Address - Phone:609-714-0202
Mailing Address - Fax:609-714-0303
Practice Address - Street 1:103 OLD MARLTON PIKE
Practice Address - Street 2:SUITE 215
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-8772
Practice Address - Country:US
Practice Address - Phone:609-714-0202
Practice Address - Fax:609-714-0303
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMB52139207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE22090Medicare UPIN
NJ489108Medicare ID - Type Unspecified