Healthcare Provider Details

I. General information

NPI: 1104843630
Provider Name (Legal Business Name): ANTHONY KULCZYCKI JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 HIGHLANDS PLAZA DR E DIV ALLERGY & IMMUNOLOGY, STE 300
SAINT LOUIS MO
63110-1392
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8122
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-273-5838
  • Fax: 314-273-5839
Mailing address:
  • Phone: 314-454-8917
  • Fax: 314-454-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberR7229
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: