Healthcare Provider Details

I. General information

NPI: 1689672040
Provider Name (Legal Business Name): RICK ALLEN KUKULKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5326 SWIFT RIVER CT
BRADENTON FL
34208-5463
US

IV. Provider business mailing address

5326 SWIFT RIVER CT
BRADENTON FL
34208-5463
US

V. Phone/Fax

Practice location:
  • Phone: 308-660-5567
  • Fax:
Mailing address:
  • Phone: 308-660-5567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24735
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35063049
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME 92993
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: