Provider Demographics
NPI:1639386600
Name:W. RICHARD BUKATA
Entity Type:Organization
Organization Name:W. RICHARD BUKATA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-535-4370
Mailing Address - Street 1:FILE 57430
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7430
Mailing Address - Country:US
Mailing Address - Phone:800-819-2424
Mailing Address - Fax:
Practice Address - Street 1:438 W LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1216
Practice Address - Country:US
Practice Address - Phone:626-289-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26036207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G26036OtherCA BLUE CROSS
00G260360OtherBLUE SHIELD
CA00G260360Medicaid
F17118Medicare UPIN
G26036OtherCA BLUE CROSS