Healthcare Provider Details

I. General information

NPI: 1497280507
Provider Name (Legal Business Name): LAWRENCE FITZGERALD KUKLINSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SANTA MONICA BLVD STE 510
SANTA MONICA CA
90404-2131
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90095-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-917-3376
  • Fax: 310-582-6302
Mailing address:
  • Phone: 310-301-8707
  • Fax: 310-301-8752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA159152
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: