Healthcare Provider Details

I. General information

NPI: 1235251513
Provider Name (Legal Business Name): CARL S KUKIELKA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10025 GOVERNOR WARFIELD PKWY SUITE 103
COLUMBIA MD
21044-3340
US

IV. Provider business mailing address

707 S PRESIDENT ST APT 634
BALTIMORE MD
21202-4474
US

V. Phone/Fax

Practice location:
  • Phone: 410-772-5412
  • Fax: 410-828-2018
Mailing address:
  • Phone: 410-772-5412
  • Fax: 410-828-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA0752
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: