Provider Demographics
NPI:1790966646
Name:SCOTT M. BUCKINGHAM, OD PC
Entity Type:Organization
Organization Name:SCOTT M. BUCKINGHAM, OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:OVERLY
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC, NAO
Authorized Official - Phone:989-636-7580
Mailing Address - Street 1:2808 W WACKERLY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6997
Mailing Address - Country:US
Mailing Address - Phone:989-636-7580
Mailing Address - Fax:989-636-7583
Practice Address - Street 1:2808 W WACKERLY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6997
Practice Address - Country:US
Practice Address - Phone:989-636-7580
Practice Address - Fax:989-636-7583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI003193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900E611320OtherBLUE CROSS BLUE SHIELD
MIT96958Medicare UPIN
MI900E611320OtherBLUE CROSS BLUE SHIELD
MI0992990001Medicare NSC