Healthcare Provider Details

I. General information

NPI: 1568437507
Provider Name (Legal Business Name): SLAVKO KUKUCKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 CHIMNEY RD
RINCON GA
31326
US

IV. Provider business mailing address

119 CHIMNEY RD
RINCON GA
31326
US

V. Phone/Fax

Practice location:
  • Phone: 912-826-0229
  • Fax: 912-826-0449
Mailing address:
  • Phone: 912-826-0229
  • Fax: 912-826-0449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number046877
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: