Provider Demographics
NPI:1952926776
Name:CHILDERS, MASON BUCKLEY (OD)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:BUCKLEY
Last Name:CHILDERS
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 1:996 COUNTY ROAD 57
Mailing Address - Street 2:
Mailing Address - City:SKIPPERVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36374-6863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6020 BOLL WEEVIL CIR
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-9420
Practice Address - Country:US
Practice Address - Phone:334-347-2732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-E46152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist