Healthcare Provider Details

I. General information

NPI: 1205836954
Provider Name (Legal Business Name): ROMAN PLATON BUKACHEVSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 POSADA LN SUITE B
TEMPLETON CA
93465-4055
US

IV. Provider business mailing address

295 POSADA LN SUITE B
TEMPLETON CA
93465-4055
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-5960
  • Fax: 805-434-5963
Mailing address:
  • Phone: 805-434-5960
  • Fax: 805-434-5963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG71259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: