Provider Demographics
NPI:1023016987
Name:KULICK, SAMUEL D (DPM)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:D
Last Name:KULICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 UNIVERSITY BLVD S
Mailing Address - Street 2:BLDG C
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4250
Mailing Address - Country:US
Mailing Address - Phone:904-731-1711
Mailing Address - Fax:904-731-9270
Practice Address - Street 1:3636 UNIVERSITY BLVD S
Practice Address - Street 2:BLDG C
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4250
Practice Address - Country:US
Practice Address - Phone:904-731-1711
Practice Address - Fax:904-731-9270
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3308213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00784166OtherRAILROAD MEDICARE
FL65978OtherBCBS
FLCE918AMedicare PIN
65978Medicare PIN
FLAG003YMedicare PIN
FLAG003ZMedicare PIN
P00784166OtherRAILROAD MEDICARE