Healthcare Provider Details

I. General information

NPI: 1881787802
Provider Name (Legal Business Name): WALTER DEAN KUCABA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 E MAIN ST
DUNCAN SC
29334-9218
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-3500
  • Fax: 864-560-3522
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0608
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: