Provider Demographics
NPI:1992876056
Name:BUCKINGHAM, TAD WILLIS (OD)
Entity type:Individual
Prefix:
First Name:TAD
Middle Name:WILLIS
Last Name:BUCKINGHAM
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 1:7615 SW SPEAKS DR
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:OR
Mailing Address - Zip Code:97119-9117
Mailing Address - Country:US
Mailing Address - Phone:503-459-9247
Mailing Address - Fax:503-357-5493
Practice Address - Street 1:7615 SW SPEAKS DR
Practice Address - Street 2:
Practice Address - City:GASTON
Practice Address - State:OR
Practice Address - Zip Code:97119-9117
Practice Address - Country:US
Practice Address - Phone:503-459-9247
Practice Address - Fax:503-357-5493
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4022ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist