Healthcare Provider Details

I. General information

NPI: 1942695556
Provider Name (Legal Business Name): CALEN WADE KUCERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 07/12/2024
Certification Date: 07/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234
US

IV. Provider business mailing address

1915 KERRISDALE DR
SAN ANTONIO TX
78260-4423
US

V. Phone/Fax

Practice location:
  • Phone: 830-431-1169
  • Fax:
Mailing address:
  • Phone: 830-431-1169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number210002356
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number0101275032
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: