Basic Information
| Provider Information | |||||||||
| NPI: | 1922209451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCHANAN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LOU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FITZGIBBON | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LOU | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1825 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490012762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693420003 | ||||||||
| FaxNumber: | 2693424284 | ||||||||
| Practice Location | |||||||||
| Address1: | 6749 CASCADE RD SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495466849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169573099 | ||||||||
| FaxNumber: | 6169573729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901004421 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1922209451 | 05 | MI | MEDICAID |