Provider Demographics
NPI:1063756658
Name:BUKONG, ERIC
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:BUKONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6731 NEW HAMPSHIRE AVE
Mailing Address - Street 2:#1006W
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-4863
Mailing Address - Country:US
Mailing Address - Phone:240-938-7990
Mailing Address - Fax:
Practice Address - Street 1:7506 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1608
Practice Address - Country:US
Practice Address - Phone:202-291-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide