Healthcare Provider Details

I. General information

NPI: 1366994485
Provider Name (Legal Business Name): ANDREA BUKOWSKI RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 SCHNIER ST
COLUMBUS IN
47201-2619
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-376-5780
  • Fax: 812-376-5781
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number949620
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001777A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: