Basic Information
| Provider Information | |||||||||
| NPI: | 1669484291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUKULA | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 E VENICE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342923190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414839760 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1700 E VENICE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342923190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414839760 | ||||||||
| FaxNumber: | 9414839775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | OS7394 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207Q00000X | OS7394 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 252789800 | 05 | FL | MEDICAID |