Provider Demographics
NPI:1073524104
Name:KULAKOV, SLAVA I (MD)
Entity Type:Individual
Prefix:DR
First Name:SLAVA
Middle Name:I
Last Name:KULAKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 MAIN ST
Mailing Address - Street 2:STE 100
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2810
Mailing Address - Country:US
Mailing Address - Phone:203-255-0695
Mailing Address - Fax:203-255-0629
Practice Address - Street 1:134 ROUND HILL RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824
Practice Address - Country:US
Practice Address - Phone:203-255-0695
Practice Address - Fax:203-255-0629
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036896207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001368960Medicaid
CT010036896CT01OtherBCBS
CTOV4890OtherHEALTHNET
R01031Medicare UPIN
CT110006808Medicare ID - Type Unspecified