Provider Demographics
NPI:1982743043
Name:BUCKWALTER, DALE LEROY (OD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:LEROY
Last Name:BUCKWALTER
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:PO BOX 720084
Mailing Address - Street 2:
Mailing Address - City:PINON HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92372
Mailing Address - Country:US
Mailing Address - Phone:760-868-2101
Mailing Address - Fax:760-868-2101
Practice Address - Street 1:2248 D ST
Practice Address - Street 2:
Practice Address - City:LAVERNE
Practice Address - State:CA
Practice Address - Zip Code:91750
Practice Address - Country:US
Practice Address - Phone:909-593-3519
Practice Address - Fax:909-593-3521
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5015T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TO9851Medicare UPIN