Provider Demographics
NPI:1598703779
Name:BUKATA, PABLO A (MD)
Entity Type:Individual
Prefix:MR
First Name:PABLO
Middle Name:A
Last Name:BUKATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1101 E GLENDALE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383
Mailing Address - Country:US
Mailing Address - Phone:219-462-0555
Mailing Address - Fax:219-548-3681
Practice Address - Street 1:1101 E GLENDALE BLVD
Practice Address - Street 2:STE 101
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:219-462-0555
Practice Address - Fax:219-548-3681
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ININ01047064208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000183895OtherANTHEM
IN200218810Medicaid
IN200218810Medicaid