Healthcare Provider Details

I. General information

NPI: 1992972376
Provider Name (Legal Business Name): MAX JOSEPH KUKLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4617 CHARDONNAY CT
ATLANTA GA
30338
US

IV. Provider business mailing address

4617 CHARDONNAY CT
ATLANTA GA
30338
US

V. Phone/Fax

Practice location:
  • Phone: 770-604-9071
  • Fax: 770-604-3034
Mailing address:
  • Phone: 770-604-9071
  • Fax: 770-604-3034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101005518
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: