Provider Demographics
NPI:1295715456
Name:KULA, ROGER W (MD, FAAN)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:KULA
Suffix:
Gender:M
Credentials:MD, FAAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-5539
Practice Address - Street 1:865 NORTHERN BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5310
Practice Address - Country:US
Practice Address - Phone:516-570-4425
Practice Address - Fax:516-570-4444
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1103112084N0400X, 2084N0008X
MD110311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00197026Medicaid
NY475N11Medicare ID - Type Unspecified
NY00197026Medicaid