Provider Demographics
NPI: | 1558365031 |
---|---|
Name: | BUFILL, JOSE A (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOSE |
Middle Name: | A |
Last Name: | BUFILL |
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: | 100 E WAYNE ST STE 510 |
Mailing Address - Street 2: | |
Mailing Address - City: | SOUTH BEND |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46601-2349 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 574-334-5390 |
Mailing Address - Fax: | 574-334-5368 |
Practice Address - Street 1: | 5340 HOLY CROSS PKWY |
Practice Address - Street 2: | |
Practice Address - City: | MISHAWAKA |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46545-1470 |
Practice Address - Country: | US |
Practice Address - Phone: | 574-237-1328 |
Practice Address - Fax: | 574-968-9442 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-13 |
Last Update Date: | 2018-01-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01041769A | 207RH0003X, 207RX0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RX0202X | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 100114430 | Medicaid | |
IN | 216950H | Medicare PIN | |
E89678 | Medicare UPIN |