Provider Demographics
NPI:1235251513
Name:KUKIELKA, CARL S (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:S
Last Name:KUKIELKA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:707 S PRESIDENT ST
Mailing Address - Street 2:APT 634
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4474
Mailing Address - Country:US
Mailing Address - Phone:410-772-5412
Mailing Address - Fax:410-828-2018
Practice Address - Street 1:10025 GOVERNOR WARFIELD PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3340
Practice Address - Country:US
Practice Address - Phone:410-772-5412
Practice Address - Fax:410-828-2018
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist