Healthcare Provider Details

I. General information

NPI: 1710564968
Provider Name (Legal Business Name): KRISTINA KUKLOVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

236 FARMINGTON AVENUE
FARMINGTON CT
06030-1921
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-8080
  • Fax: 860-679-1340
Mailing address:
  • Phone: 860-670-2147
  • Fax: 860-679-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: