Provider Demographics
NPI: | 1609869551 |
---|---|
Name: | KUKIN, MARRICK L (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MARRICK |
Middle Name: | L |
Last Name: | KUKIN |
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: | 130 E 77TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW YORK |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10075-1851 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 212-535-6340 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 158 E 84TH ST |
Practice Address - Street 2: | |
Practice Address - City: | NEW YORK |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10028-2005 |
Practice Address - Country: | US |
Practice Address - Phone: | 212-535-6340 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-25 |
Last Update Date: | 2018-10-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 155168 | 207RC0000X |
NY | 155618 | 207RA0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RA0001X | Allopathic & Osteopathic Physicians | Internal Medicine | Advanced Heart Failure and Transplant Cardiology |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 01105820 | Medicaid | |
NY | 01105820 | Medicaid | |
NY | A60978 | Medicare UPIN |