Healthcare Provider Details

I. General information

NPI: 1336194307
Provider Name (Legal Business Name): LAURIE ANN KUKAS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 NW 47TH ST STE A
OKLAHOMA CITY OK
73118-6412
US

IV. Provider business mailing address

1024 NW 47TH ST STE A
OKLAHOMA CITY OK
73118-6412
US

V. Phone/Fax

Practice location:
  • Phone: 405-528-0303
  • Fax: 405-528-0677
Mailing address:
  • Phone: 405-528-0303
  • Fax: 405-528-0677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number2704
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: