Provider Demographics
NPI:1467457051
Name:BUCKINGHAM, SCOTT MASON (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MASON
Last Name:BUCKINGHAM
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 1:1504 HARCREST DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4717
Mailing Address - Country:US
Mailing Address - Phone:989-636-7580
Mailing Address - Fax:989-636-7583
Practice Address - Street 1:1504 HARCREST DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4717
Practice Address - Country:US
Practice Address - Phone:989-636-7580
Practice Address - Fax:989-636-7583
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
MI003193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA900E66505OtherBCBS OF MICHIGAN
MA0992990001OtherADMINISTAR FEDERAL
MI005131OtherVSP
MA900E66505OtherBCBS OF MICHIGAN
MI0M02100Medicare ID - Type Unspecified