Provider Demographics
NPI:1003875386
Name:BUCHLI, IAN (OD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:BUCHLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 VILLAGE AT GLYNN PL
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-1993
Mailing Address - Country:US
Mailing Address - Phone:912-264-6000
Mailing Address - Fax:912-264-0808
Practice Address - Street 1:90 VILLAGE AT GLYNN PL
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-1993
Practice Address - Country:US
Practice Address - Phone:912-264-6000
Practice Address - Fax:912-264-0808
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000954291BMedicaid
GA000954291AMedicaid
GA000954291BMedicaid
GA41ZCDVSMedicare PIN