Healthcare Provider Details

I. General information

NPI: 1710986427
Provider Name (Legal Business Name): GILBERT L KUKIELKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SAINT FRANCIS DR STE 15
CAPE GIRARDEAU MO
63703-5049
US

IV. Provider business mailing address

PO BOX 801143
KANSAS CITY MO
64180-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-331-3333
  • Fax: 573-331-3334
Mailing address:
  • Phone: 573-331-5583
  • Fax: 573-331-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2020012709
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number2020012709
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: