Provider Demographics
NPI:1710946470
Name:CHARLES V KLUCKA DO PA
Entity Type:Organization
Organization Name:CHARLES V KLUCKA DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:V
Authorized Official - Last Name:KLUCKA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-939-2246
Mailing Address - Street 1:9671 GLADIOLUS DR
Mailing Address - Street 2:SUITE #104
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7606
Mailing Address - Country:US
Mailing Address - Phone:239-939-2246
Mailing Address - Fax:239-267-2929
Practice Address - Street 1:9671 GLADIOLUS DR
Practice Address - Street 2:SUITE #104
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-7606
Practice Address - Country:US
Practice Address - Phone:239-939-2246
Practice Address - Fax:239-267-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S 0006759207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AM603AMedicare PIN
FLF87731Medicare UPIN