Healthcare Provider Details

I. General information

NPI: 1366546947
Provider Name (Legal Business Name): CHARLES BUKOVINSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 GREAT TEAYS BLVD SUITE 6
SCOTT DEPOT WV
25560-9815
US

IV. Provider business mailing address

97 GREAT TEAYS BLVD SUITE 6
SCOTT DEPOT WV
25560-9815
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-6999
  • Fax: 304-757-3252
Mailing address:
  • Phone: 304-757-6999
  • Fax: 304-757-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15584
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: