Healthcare Provider Details

I. General information

NPI: 1225074180
Provider Name (Legal Business Name): ANDREW IAN BUKOVITZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 S HANOVER ST
BALTIMORE MD
21225-1233
US

IV. Provider business mailing address

307 S EVERGREEN AVE
WOODBURY NJ
08096-2739
US

V. Phone/Fax

Practice location:
  • Phone: 410-350-3509
  • Fax: 410-350-3511
Mailing address:
  • Phone: 856-686-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD61438
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: