Provider Demographics
NPI:1144263104
Name:KUCZKOWSKI, MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KUCZKOWSKI
Suffix:
Gender:M
Credentials:PA
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 863026
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3026
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-308-8435
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0002852207P00000X
FLPA2852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL970007146OtherRAILROAD MEDICARE
FLE0361Medicare ID - Type Unspecified
FLS51436Medicare UPIN