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General NPI Number Information
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NPI Number | 1912598699
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Entity Type | Organization
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Legal Business Name | MBK GASTRO LLC
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Dates
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Enumeration Date | 01/27/2021
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Last Update Date | 03/29/2021
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Provider Practice Location Address
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Address Line | 763 OLD NORCROSS RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4317
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Country | US
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Telephone | 770-883-1176
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Fax | 678-985-1999
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Provider Business Mailing Address
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Address Line | 763 OLD NORCROSS RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4317
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Country | US
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Telephone | 770-883-1176
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Fax | 678-985-1999
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Authorized Official
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Title or Position | MANAGING PHYSICIAN
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Name | MARK B KUKLER
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Credential | DO
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Telephone | 770-883-1176
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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