Healthcare Provider Details

I. General information

NPI: 1093765265
Provider Name (Legal Business Name): MARK B. KUKLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4317
US

IV. Provider business mailing address

763 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4317
US

V. Phone/Fax

Practice location:
  • Phone: 678-985-2000
  • Fax: 678-985-1999
Mailing address:
  • Phone: 678-985-2000
  • Fax: 678-985-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036800
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: