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NPI Code Detail

MEDICARE: MARY K KUKOLICH MD

MEDICARE: MARY K KUKOLICH MD
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
1208000000XPediatrics PhysicianE5817TX
2207SG0201XClinical Genetics (M.D.) PhysicianE5817TX

General Provider Information

NPI Number : 1912918111
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY K KUKOLICH MD
Provider Business Mailing Address
First Line : PO BOX 733784
Second Line :
City : DALLAS
State : TX
Zip : 75373-3784
Country : US
Telephone Number : 682-885-1855
Fax Number : 682-885-1396
Provider Business Practice Location Address
First Line : 750 8TH AVE STE 200
Second Line :
City : FORT WORTH
State : TX
Zip : 76104-2500
Country : US
Telephone Number : 682-885-2170
Fax Number : 817-335-8277
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/11/2006
Last Update Date : 05/17/2021

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Directions to “ MARY K KUKOLICH MD” Practice Location

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