Provider Demographics
NPI:1588603286
Name:BUKSAR, BRYAN MICHAEL (PT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:MICHAEL
Last Name:BUKSAR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 WEST 17TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46406
Mailing Address - Country:US
Mailing Address - Phone:219-944-4036
Mailing Address - Fax:
Practice Address - Street 1:7101 WEST 17TH AVENUE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46406
Practice Address - Country:US
Practice Address - Phone:219-944-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:2008-06-05
Provider Licenses
StateLicense IDTaxonomies
IN05006766A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist