Provider Demographics
NPI:1073838629
Name:KASULKE, MATTHEW DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:KASULKE
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 1:17 LANSING ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1983
Mailing Address - Country:US
Mailing Address - Phone:315-253-1832
Mailing Address - Fax:315-702-8393
Practice Address - Street 1:SURGICAL SERVICES OF AUBURN
Practice Address - Street 2:77 NELSON STREET, SUITE 320
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021
Practice Address - Country:US
Practice Address - Phone:315-253-1832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284157208600000X
CT054068390200000X
CT54068208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program