Provider Demographics
NPI:1245271840
Name:BUCZKO, MATTHEW STEPHEN (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:BUCZKO
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 1:42 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2623
Mailing Address - Country:US
Mailing Address - Phone:309-647-2020
Mailing Address - Fax:309-647-8944
Practice Address - Street 1:42 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2623
Practice Address - Country:US
Practice Address - Phone:309-647-2020
Practice Address - Fax:309-647-8944
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009571152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3142002Medicare PIN
ILU96424Medicare UPIN
IL6337240001Medicare NSC