Healthcare Provider Details

I. General information

NPI: 1366787053
Provider Name (Legal Business Name): ROBERT KUCEJKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 04/26/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 STOCKTON BLVD STE E
SACRAMENTO CA
95817-1418
US

IV. Provider business mailing address

2335 STOCKTON BLVD. NAOB 6TH FLOOR
WEST SACRAMENTO CA
95617
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2680
  • Fax:
Mailing address:
  • Phone: 916-734-9031
  • Fax: 916-703-4452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA178559
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: