Healthcare Provider Details

I. General information

NPI: 1083955108
Provider Name (Legal Business Name): NICOLE MARIE KUCERA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 08/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3443 S NATIONAL AVE
SPRINGFIELD MO
65807
US

IV. Provider business mailing address

3443 S NATIONAL AVE
SPRINGFIELD MO
65807-7308
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-2000
  • Fax: 417-269-2038
Mailing address:
  • Phone: 417-269-2000
  • Fax: 417-269-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2016025648
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500137105
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: