Provider Demographics
NPI:1568437507
Name:KUKUCKA, SLAVKO (MD)
Entity Type:Individual
Prefix:
First Name:SLAVKO
Middle Name:
Last Name:KUKUCKA
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 1:119 CHIMNEY RD
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326
Mailing Address - Country:US
Mailing Address - Phone:912-826-0229
Mailing Address - Fax:912-826-0449
Practice Address - Street 1:119 CHIMNEY RD
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326
Practice Address - Country:US
Practice Address - Phone:912-826-0229
Practice Address - Fax:912-826-0449
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52782040-008OtherBCBS GA FOR SAVANNAH LOCATION
SCG46877Medicaid
GA582203199-009OtherTRICARE ID
GACG4057OtherRR MEDICARE GROUP ID
SCGPA892OtherSC MEDICAID GROUP ID FOR POOLER LOCATION
GAGRP2837OtherMEDICARE GROUP ID
GA000843235EMedicaid
GA000843235CMedicaid
GA52782040-009OtherBCBS/GA FOR POOLER LOCATION
GA000843235DMedicaid
SCGPA902OtherSC MEDICAID GROUP ID FOR SAVANNAH LOCATION
GA582203199-004OtherTRICARE ID
GAP00441748OtherRR MEDICARE
GA08BBSKZMedicare PIN
GA582203199-004OtherTRICARE ID
SCGPA902OtherSC MEDICAID GROUP ID FOR SAVANNAH LOCATION