Provider Demographics
NPI:1073817300
Name:LA KOCUR WILDE PC
Entity Type:Organization
Organization Name:LA KOCUR WILDE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOCUR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-696-6078
Mailing Address - Street 1:134 REBEL RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2383
Mailing Address - Country:US
Mailing Address - Phone:215-696-6078
Mailing Address - Fax:610-265-2695
Practice Address - Street 1:134 REBEL RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2383
Practice Address - Country:US
Practice Address - Phone:215-696-6078
Practice Address - Fax:610-265-2695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003384L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty