Provider Demographics
NPI:1922209451
Name:BUCHANAN, AMY LOU (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LOU
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LOU
Other - Last Name:FITZGIBBON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1825 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-2762
Mailing Address - Country:US
Mailing Address - Phone:269-342-0003
Mailing Address - Fax:269-342-4284
Practice Address - Street 1:6749 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6849
Practice Address - Country:US
Practice Address - Phone:616-957-3099
Practice Address - Fax:616-957-3729
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004421152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1922209451Medicaid
MI0D17001Medicare PIN