Basic Information
| Provider Information | |||||||||
| NPI: | 1659634848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKLEY | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1816 FENWICK AVE | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547014418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155790576 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4800 GOLF RD STE 127 | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547019049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158348404 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2012 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3549 | MN | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 3273-35 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 020677066 | 01 | WI | VISIONWORKS | OTHER |