Provider Demographics
NPI:1013681774
Name:KULAK OCULOFACIAL LLC
Entity Type:Organization
Organization Name:KULAK OCULOFACIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KULAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-715-2599
Mailing Address - Street 1:530 JACKSONVILLE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3813
Mailing Address - Country:US
Mailing Address - Phone:904-775-5275
Mailing Address - Fax:904-853-1414
Practice Address - Street 1:530 JACKSONVILLE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3813
Practice Address - Country:US
Practice Address - Phone:904-775-5275
Practice Address - Fax:904-853-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-05
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty