Provider Demographics
NPI:1528195625
Name:ROMAN P. BUKACHEVSKY, MD, INC
Entity Type:Organization
Organization Name:ROMAN P. BUKACHEVSKY, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BUKACHEVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-434-5960
Mailing Address - Street 1:295 POSADA LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-4055
Mailing Address - Country:US
Mailing Address - Phone:805-434-5960
Mailing Address - Fax:805-434-5963
Practice Address - Street 1:295 POSADA LN
Practice Address - Street 2:SUITE B
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4055
Practice Address - Country:US
Practice Address - Phone:805-434-5960
Practice Address - Fax:805-434-5963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71259174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G712591Medicaid
CA00G712591Medicaid