Provider Demographics
NPI:1346219557
Name:BULLER, JUANCARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUANCARLOS
Middle Name:
Last Name:BULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 PEAR TREE LN STE 100
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6485
Mailing Address - Country:US
Mailing Address - Phone:707-254-1770
Mailing Address - Fax:707-254-1779
Practice Address - Street 1:300 HARTLE CT
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-4078
Practice Address - Country:US
Practice Address - Phone:707-254-1775
Practice Address - Fax:707-254-1779
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66601207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A666010OtherBLUE SHIELD PIN
CA00A666010OtherBLUE SHIELD PIN
CA00A666013Medicare PIN
CAH08453Medicare UPIN