Provider Demographics
NPI:1760491278
Name:KULAS, ROGER W (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:KULAS
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 1:610 S LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1215
Mailing Address - Country:US
Mailing Address - Phone:906-786-6488
Mailing Address - Fax:
Practice Address - Street 1:610 S LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1215
Practice Address - Country:US
Practice Address - Phone:906-786-6488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3367387Medicaid
MI080109602OtherRR MEDICARE GROUP#CC2139
MI3367387Medicaid
MI0M05250016Medicare ID - Type Unspecified
MIOP38340031Medicare Oscar/Certification