Healthcare Provider Details

I. General information

NPI: 1841455417
Provider Name (Legal Business Name): JOHN LAWRENCE KUCERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7606 N UNION BLVD SUITE A
COLORADO SPRINGS CO
80920-3850
US

IV. Provider business mailing address

7606 N UNION BLVD SUITE A
COLORADO SPRINGS CO
80920-3850
US

V. Phone/Fax

Practice location:
  • Phone: 719-596-1118
  • Fax: 719-573-9774
Mailing address:
  • Phone: 719-596-1118
  • Fax: 719-573-9774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26883
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: