Provider Demographics
NPI:1932140639
Name:BUKATA, SUSAN V (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:V
Last Name:BUKATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1250 16TH ST
Mailing Address - Street 2:SUITE 3142
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1249
Mailing Address - Country:US
Mailing Address - Phone:424-259-9816
Mailing Address - Fax:424-259-6591
Practice Address - Street 1:1250 16TH ST
Practice Address - Street 2:SUITE 3142
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1249
Practice Address - Country:US
Practice Address - Phone:424-259-9816
Practice Address - Fax:424-259-6591
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC55109207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I12633Medicare UPIN
CAGA150ZMedicare PIN