Healthcare Provider Details

I. General information

NPI: 1023016987
Provider Name (Legal Business Name): SAMUEL D KULICK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9397 SAN JOSE BLVD UNIT 1
JACKSONVILLE FL
32257-5637
US

IV. Provider business mailing address

9397 SAN JOSE BLVD UNIT 1
JACKSONVILLE FL
32257-5637
US

V. Phone/Fax

Practice location:
  • Phone: 904-731-9293
  • Fax: 904-636-0223
Mailing address:
  • Phone: 904-731-9293
  • Fax: 904-636-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO3308
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: