Provider Demographics
NPI:1578825956
Name:KUGZRUK, DICK BAKER (CHA III)
Entity Type:Individual
Prefix:
First Name:DICK
Middle Name:BAKER
Last Name:KUGZRUK
Suffix:
Gender:M
Credentials:CHA III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85058 WEST CLARENCE ROAD
Mailing Address - Street 2:
Mailing Address - City:BREVIG
Mailing Address - State:AK
Mailing Address - Zip Code:99785
Mailing Address - Country:US
Mailing Address - Phone:907-642-4311
Mailing Address - Fax:907-642-2216
Practice Address - Street 1:85058 WEST CLARENCE ROAD
Practice Address - Street 2:
Practice Address - City:BREVIG
Practice Address - State:AK
Practice Address - Zip Code:99785
Practice Address - Country:US
Practice Address - Phone:907-642-4311
Practice Address - Fax:907-642-2216
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12-1178-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK12-1178-IIIOtherCHA III