Provider Demographics
NPI:1992972376
Name:KUKLER, MAX JOSEPH (DO)
Entity type:Individual
Prefix:DR
First Name:MAX
Middle Name:JOSEPH
Last Name:KUKLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4617 CHARDONNAY CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338
Mailing Address - Country:US
Mailing Address - Phone:770-604-9071
Mailing Address - Fax:770-604-3034
Practice Address - Street 1:4617 CHARDONNAY CT
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-604-9071
Practice Address - Fax:770-604-3034
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3441760Medicaid
MI3441760Medicaid