Provider Demographics
NPI:1669484291
Name:KUKULA, CHRISTINA (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:KUKULA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-3190
Mailing Address - Country:US
Mailing Address - Phone:941-483-9760
Mailing Address - Fax:
Practice Address - Street 1:1700 E VENICE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-3190
Practice Address - Country:US
Practice Address - Phone:941-483-9760
Practice Address - Fax:941-483-9775
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7394207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252789800Medicaid
57555Medicare ID - Type Unspecified