Provider Demographics
NPI:1437245867
Name:BUKATY, LISA M (MD)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:BUKATY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 309
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-644-8556
Mailing Address - Fax:949-644-6318
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 309
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-644-8556
Practice Address - Fax:949-644-6318
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72364207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G723640OtherBLUE SHIELD OF CALIFORNIA
CAWG72364AMedicare ID - Type Unspecified
CA00G723640OtherBLUE SHIELD OF CALIFORNIA