Healthcare Provider Details

I. General information

NPI: 1558848325
Provider Name (Legal Business Name): TIMOTHY KUCKUK AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 W LOOMIS RD
GREENFIELD WI
53220-4858
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-281-4466
  • Fax: 414-281-4564
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number672-156
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: