Provider Demographics
NPI:1174561492
Name:BUKATA, WALTER RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:RICHARD
Last Name:BUKATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 57430
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26036207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG26036OtherCA BLUE CROSS
CA00G260360Medicaid
00G260360OtherBLUE SHIELD
00G260360OtherBLUE SHIELD
G26036Medicare PIN