Provider Demographics
NPI:1619056058
Name:KUKREJA, PROMIL
Entity type:Individual
Prefix:
First Name:PROMIL
Middle Name:
Last Name:KUKREJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1115
Mailing Address - Country:US
Mailing Address - Phone:407-514-3668
Mailing Address - Fax:321-843-2196
Practice Address - Street 1:62 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1115
Practice Address - Country:US
Practice Address - Phone:407-514-3668
Practice Address - Fax:321-843-2196
Is Sole Proprietor?:No
Enumeration Date:2006-11-05
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29673207L00000X
FLME166096207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122330500Medicaid
AL051065074OtherBLUE CROSS
AL051065075OtherBLUE CROSS
AL051065081OtherBLUE CROSS
AL114120Medicaid
AL114117Medicaid
AL114121Medicaid
ALP00779102OtherRAILROAD MEDICARE
MS03204235Medicaid
AL114119Medicaid
AL114119Medicaid