Healthcare Provider Details

I. General information

NPI: 1790966646
Provider Name (Legal Business Name): SCOTT M. BUCKINGHAM, OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 W WACKERLY ST SUITE 1
MIDLAND MI
48640-6997
US

IV. Provider business mailing address

2808 W WACKERLY ST SUITE 1
MIDLAND MI
48640-6997
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: MRS. JERI L OVERLY
Title or Position: OFFICE MANAGER
Credential: ABOC, NAO
Phone: 989-636-7580