Provider Demographics
NPI:1881787802
Name:KUCABA, WALTER DEAN (DO)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:DEAN
Last Name:KUCABA
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1575 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-9218
Practice Address - Country:US
Practice Address - Phone:864-560-3500
Practice Address - Fax:864-560-3522
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC216950OtherMEDCOST
SC7132885OtherAETNA
SC006086Medicaid
SCH545106067Medicare PIN
H54510Medicare UPIN
SCH545104862Medicare PIN
SCP00386453Medicare PIN
SCH54510Medicare PIN