Provider Demographics
NPI:1922760107
Name:LULKOVICH, KALEY NICHOLE
Entity Type:Individual
Prefix:
First Name:KALEY
Middle Name:NICHOLE
Last Name:LULKOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N IH 35 STE C2.230
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1926
Mailing Address - Country:US
Mailing Address - Phone:512-324-8221
Mailing Address - Fax:
Practice Address - Street 1:1501 RED RIVER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1845
Practice Address - Country:US
Practice Address - Phone:512-495-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX764823207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program