=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073850392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KONSTANTIN BUKOV, M.D. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2013
-----------------------------------------------------
Last Update Date | 01/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2299 POST ST SUITE 303
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94115-3441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-440-6800
-----------------------------------------------------
Fax | 415-586-6171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 WILLOW AVE APT 302
-----------------------------------------------------
City | BURLINGAME
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94010-5072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KONSTANTIN BUKOV
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 415-440-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A116876
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------