Provider Demographics
NPI:1093765265
Name:KUKLER, MARK B (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:KUKLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:763 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:678-985-2000
Mailing Address - Fax:678-985-1999
Practice Address - Street 1:763 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:678-985-2000
Practice Address - Fax:678-985-1999
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA036800207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00540185BMedicaid
GA309492OtherWELLCARE
GA00540185BMedicaid
GAF54632Medicare UPIN