Provider Demographics
NPI:1811004351
Name:KUCERA, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:KUCERA
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 1:5814 GRAHAM AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-2728
Mailing Address - Country:US
Mailing Address - Phone:253-891-7450
Mailing Address - Fax:
Practice Address - Street 1:5814 GRAHAM AVE STE 100
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-2728
Practice Address - Country:US
Practice Address - Phone:253-891-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41843207Q00000X
IL36085832207Q00000X
WAMD60057955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI521100514Medicare UPIN