Healthcare Provider Details

I. General information

NPI: 1811004351
Provider Name (Legal Business Name): CHARLES J KUCERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5814 GRAHAM AVE STE 100
SUMNER WA
98390-2728
US

IV. Provider business mailing address

5814 GRAHAM AVE STE 100
SUMNER WA
98390-2728
US

V. Phone/Fax

Practice location:
  • Phone: 253-891-7450
  • Fax:
Mailing address:
  • Phone: 253-891-7450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41843
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36085832
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60057955
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: