=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356341440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEDRO BUKATA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2005
-----------------------------------------------------
Last Update Date | 10/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 S PRAIRIE AVE #1206
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-3043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-786-1152
-----------------------------------------------------
Fax | 312-786-1152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 S PRAIRIE AVE #1206
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-3043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-786-1152
-----------------------------------------------------
Fax | 312-786-1152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 01026572A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------