Healthcare Provider Details

I. General information

NPI: 1487672440
Provider Name (Legal Business Name): TIMOTHY RAY KUKLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/09/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 19TH AVE STE 3800
DENVER CO
80218-1252
US

IV. Provider business mailing address

4900 S MONACO ST STE 210
DENVER CO
80237-3487
US

V. Phone/Fax

Practice location:
  • Phone: 303-563-2755
  • Fax: 303-861-6219
Mailing address:
  • Phone: 303-563-2755
  • Fax: 303-861-6219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number48576
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: