MEDICARE: LAURIE ANN KUKAS D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0006X	Developmental - Behavioral Pediatrics Physician	2704	OK

General Provider Information

NPI Number	:	1336194307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE ANN KUKAS D.O.

Provider Business Mailing Address
First Line	:	1024 NW 47TH ST
Second Line	:	STE A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-6412
Country	:	US
Telephone Number	:	405-528-0303
Fax Number	:	405-528-0677

Provider Business Practice Location Address
First Line	:	1024 NW 47TH ST
Second Line	:	STE A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-6412
Country	:	US
Telephone Number	:	405-528-0303
Fax Number	:	405-528-0677

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	06/29/2010

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