Healthcare Provider Details

I. General information

NPI: 1821028879
Provider Name (Legal Business Name): A. PETER BUKEAVICH JR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 KENNEDY DR
MARTIN TN
38237-3340
US

IV. Provider business mailing address

145 KENNEDY DR
MARTIN TN
38237-3340
US

V. Phone/Fax

Practice location:
  • Phone: 731-587-2020
  • Fax: 731-587-4015
Mailing address:
  • Phone: 731-587-2020
  • Fax: 731-587-4015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD-1138 T
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: