Provider Demographics
NPI:1366546947
Name:BUKOVINSKY, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BUKOVINSKY
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 1:97 GREAT TEAYS BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9815
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-757-3252
Practice Address - Street 1:97 GREAT TEAYS BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9815
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-757-3252
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0042568000Medicaid
000434450OtherBLUE CROSS BLUE SHIELD
WV00786626OtherRR
WVWV5957AMedicare PIN
WV00786626OtherRR
WV0671762Medicare PIN