Provider Demographics
NPI:1003048265
Name:KULAK, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:KULAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:KULAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:970 N SPOEDE RD
Mailing Address - Street 2:37
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-5567
Mailing Address - Country:US
Mailing Address - Phone:314-991-9139
Mailing Address - Fax:
Practice Address - Street 1:970 N SPOEDE RD
Practice Address - Street 2:37
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-5567
Practice Address - Country:US
Practice Address - Phone:314-991-9139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002002061103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO193400000XOtherRETIRED-PSYCHIATRIST