Provider Demographics
NPI:1558473769
Name:KUCHARCHIK, THOMAS (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:KUCHARCHIK
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 1:635 MAIN ST
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:481 GOLD STAR HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6702
Practice Address - Country:US
Practice Address - Phone:860-446-8858
Practice Address - Fax:860-405-2140
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT25896207Q00000X
SC9785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC097852Medicaid
761101OtherCONNECTICARE
CT030897OtherHEALTHNET
CTNLP057OtherOXFORD
SCSC11353402OtherMEDICARE PTAN
CT001258961Medicaid
010025896CT01OtherBCBS
SCSC11353402OtherMEDICARE PTAN
CT001258961Medicaid