Provider Demographics
NPI:1447990296
Name:BUCHANAN, MARCUS CLEO
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:CLEO
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:
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 864
Mailing Address - Street 2:
Mailing Address - City:CHOUTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74337-0864
Mailing Address - Country:US
Mailing Address - Phone:918-864-4665
Mailing Address - Fax:
Practice Address - Street 1:1400 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3324
Practice Address - Country:US
Practice Address - Phone:918-456-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000000000Medicaid