Provider Demographics
NPI:1699320929
Name:BUCKLEW, CHANNING F (OD)
Entity type:Individual
Prefix:
First Name:CHANNING
Middle Name:F
Last Name:BUCKLEW
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 1:14994 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-2616
Mailing Address - Country:US
Mailing Address - Phone:662-446-9000
Mailing Address - Fax:662-779-4030
Practice Address - Street 1:14994 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2616
Practice Address - Country:US
Practice Address - Phone:662-773-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist