Provider Demographics
NPI:1912918111
Name:KUKOLICH, MARY K (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:KUKOLICH
Suffix:
Gender:F
Credentials:MD
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 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:750 8TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2500
Practice Address - Country:US
Practice Address - Phone:682-885-2170
Practice Address - Fax:817-335-8277
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5817208000000X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152676601Medicaid
1750369203OtherNPI GROUP NUMBER
TX139583221Medicaid
TX139583212Medicaid
TX139583219Medicaid
TX138412512Medicaid
TX138412513Medicaid
TX00568TMedicare PIN
B24148Medicare UPIN
TX139583219Medicaid
TX139583221Medicaid
TX0097AXMedicare PIN