Healthcare Provider Details

I. General information

NPI: 1467457051
Provider Name (Legal Business Name): SCOTT MASON BUCKINGHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

1504 HARCREST DR
MIDLAND MI
48640-4717
US

IV. Provider business mailing address

1504 HARCREST DR
MIDLAND MI
48640-4717
US

V. Phone/Fax

Practice location:
  • Phone: 989-636-7580
  • Fax: 989-636-7583
Mailing address:
  • Phone: 989-636-7580
  • Fax: 989-636-7583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number003193
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: