Provider Demographics
NPI:1285197012
Name:KUKULICH, PATRICK MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:MICHAEL
Last Name:KUKULICH
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 1:833 CHESTNUT ST STE 220
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4405
Mailing Address - Country:US
Mailing Address - Phone:215-955-8465
Mailing Address - Fax:215-955-2516
Practice Address - Street 1:833 CHESTNUT ST STE 220
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4405
Practice Address - Country:US
Practice Address - Phone:215-955-8465
Practice Address - Fax:215-955-2516
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD477709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine