Provider Demographics
NPI:1699763219
Name:BUCHANAN, WIILARD EARL (OD)
Entity type:Individual
Prefix:
First Name:WIILARD
Middle Name:EARL
Last Name:BUCHANAN
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 1:20669 BOND RD NE
Mailing Address - Street 2:STE 100
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6525
Mailing Address - Country:US
Mailing Address - Phone:360-779-2020
Mailing Address - Fax:360-779-3093
Practice Address - Street 1:1135 BETHEL AVE
Practice Address - Street 2:
Practice Address - City:PT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3125
Practice Address - Country:US
Practice Address - Phone:360-895-2020
Practice Address - Fax:360-874-0048
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023539Medicaid
WA8851677Medicare ID - Type Unspecified
23672Medicare UPIN