Provider Demographics
NPI:1417215609
Name:SAMUEL D KULICK DPM
Entity Type:Organization
Organization Name:SAMUEL D KULICK DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:KULICK
Authorized Official - Last Name:D.P.M.
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-731-9293
Mailing Address - Street 1:9397 SAN JOSE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5587
Mailing Address - Country:US
Mailing Address - Phone:904-731-9293
Mailing Address - Fax:904-636-0223
Practice Address - Street 1:9397 SAN JOSE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5587
Practice Address - Country:US
Practice Address - Phone:904-731-9293
Practice Address - Fax:904-636-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3308213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty