Provider Demographics
NPI:1356341440
Name:BUKATA, PEDRO (MD)
Entity type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:
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 1:1515 S PRAIRIE AVE
Mailing Address - Street 2:#1206
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3043
Mailing Address - Country:US
Mailing Address - Phone:312-786-1152
Mailing Address - Fax:312-786-1152
Practice Address - Street 1:1515 S PRAIRIE AVE
Practice Address - Street 2:#1206
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3043
Practice Address - Country:US
Practice Address - Phone:312-786-1152
Practice Address - Fax:312-786-1152
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026572A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100096900Medicaid
IN000000081293OtherANTHEM BCBS
IN150230AMedicare PIN
IN100096900Medicaid