Healthcare Provider Details

I. General information

NPI: 1245209063
Provider Name (Legal Business Name): SUSAN JEAN KUCIRKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 INDEPENDENCE DRIVE SUITE 300
SCHNECKSVILLE PA
18078
US

IV. Provider business mailing address

4110 INDEPENDENCE DRIVE SUITE 300
SCHNECKSVILLE PA
18078
US

V. Phone/Fax

Practice location:
  • Phone: 610-769-4200
  • Fax: 610-769-4204
Mailing address:
  • Phone: 610-769-4200
  • Fax: 610-769-4204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD031979E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: