Provider Demographics
NPI:1689672040
Name:KUKULKA, RICK ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:ALLEN
Last Name:KUKULKA
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 1:5326 SWIFT RIVER CT
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5463
Mailing Address - Country:US
Mailing Address - Phone:308-660-5567
Mailing Address - Fax:
Practice Address - Street 1:5326 SWIFT RIVER CT
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5463
Practice Address - Country:US
Practice Address - Phone:308-660-5567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE247352085R0202X
OH350630492085R0202X
FLME 929932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114009000Medicaid
FLSATZWOtherFLORIDA BLUE