Provider Demographics
NPI:1043490055
Name:KLUCKA, CHARLES V (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:V
Last Name:KLUCKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9671 GLADIOLUS DR
Mailing Address - Street 2:SUITE #104
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7606
Mailing Address - Country:US
Mailing Address - Phone:239-939-2246
Mailing Address - Fax:239-267-2929
Practice Address - Street 1:9671 GLADIOLUS DR
Practice Address - Street 2:SUITE #104
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-7606
Practice Address - Country:US
Practice Address - Phone:239-939-2246
Practice Address - Fax:239-267-2929
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS 0006759207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF87731Medicare UPIN