Provider Demographics
NPI:1154664522
Name:KUKICH, STANKA (MD)
Entity type:Individual
Prefix:
First Name:STANKA
Middle Name:
Last Name:KUKICH
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 1:403 COUNCIL DR. NE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:703-255-9513
Mailing Address - Fax:
Practice Address - Street 1:403 COUNCIL DR NE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4740
Practice Address - Country:US
Practice Address - Phone:703-255-9513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031785207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine