Healthcare Provider Details

I. General information

NPI: 1043490055
Provider Name (Legal Business Name): CHARLES V. KLUCKA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9671 GLADIOLUS DR SUITE #104
FORT MYERS FL
33908-7606
US

IV. Provider business mailing address

9671 GLADIOLUS DR SUITE #104
FORT MYERS FL
33908-7606
US

V. Phone/Fax

Practice location:
  • Phone: 239-939-2246
  • Fax: 239-267-2929
Mailing address:
  • Phone: 239-939-2246
  • Fax: 239-267-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberOS 0006759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: