Provider Demographics
NPI:1477548964
Name:SALUCK, KENNETH JEFFREY (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JEFFREY
Last Name:SALUCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 BABCOCK ST NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4610
Mailing Address - Country:US
Mailing Address - Phone:321-567-7760
Mailing Address - Fax:
Practice Address - Street 1:5151 BABCOCK ST NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4610
Practice Address - Country:US
Practice Address - Phone:321-567-7760
Practice Address - Fax:321-567-7761
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 5538207QH0002X
FLOS5538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80348OtherBCBS
FL102509900Medicaid
FL80348XMedicare PIN
E59555Medicare UPIN