Provider Demographics
NPI:1609840271
Name:BUCKTHAL, PAUL EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EDWARD
Last Name:BUCKTHAL
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014657E2084N0400X
NY152834-12084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00365095Medicaid
PA130022275OtherRR MEDICARE PIN
PA0006857800001Medicaid
PACC9269OtherRR MEDICARE GROUP
PAGU039821OtherMEDICARE GROUP
PA105620N8UMedicare ID - Type Unspecified
PAGU039821OtherMEDICARE GROUP
PA0006857800001Medicaid