Provider Demographics
NPI:1710048335
Name:BUCHANAN, DEREK JAMES
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:JAMES
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 SW TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2503
Mailing Address - Country:US
Mailing Address - Phone:503-228-2154
Mailing Address - Fax:503-228-4694
Practice Address - Street 1:925 SW TAYLOR ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2503
Practice Address - Country:US
Practice Address - Phone:503-228-2154
Practice Address - Fax:503-228-4694
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORNOT APPLICABLE156FX1800X
ORNOT APPLICABLE156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR838474000OtherREGENCE BCBS PROVIDER #
ORTIN CONFIDENTIALOtherLIFEWISE
OR049424Medicaid
OR1931129593OtherVOCATIONAL REHAB VENDOR #
ORTIN CONFIDENTIALOtherSUPERIOR VISION
OR278184Medicaid
ORJ6344OtherPACIFIC SOURCE PROVIDER #
OROP1880OtherEYEMED PROVIDER #
ORTIN CONFIDENTIALOtherCARE OREGON PROVIDER
ORTIN CONFIDENTIALOtherMESO
ORTIN CONFIDENTIALOtherODS HEALTH PLAN
OR0962980002Medicare NSC