Basic Information
| Provider Information | |||||||||
| NPI: | 1932126364 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | W RICHARD BUKATA MD INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAN GABRIEL EMERGENCY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 57430 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900747430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008192424 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 438 W LAS TUNAS DR | ||||||||
| Address2: | |||||||||
| City: | SAN GABRIEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917761216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262895454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 04/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUKATA | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6268363700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ56564Z | 01 | BLUE SHIELD | OTHER | GR0082310 | 05 | CA | MEDICAID |