Provider Demographics
NPI:1932126364
Name:W RICHARD BUKATA MD INC.
Entity Type:Organization
Organization Name:W RICHARD BUKATA MD INC.
Other - Org Name:SAN GABRIEL EMERGENCY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BUKATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-836-3700
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:2006-07-15
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ56564ZOtherBLUE SHIELD
CAGR0082310Medicaid
CI2075Medicare PIN