Provider Demographics
NPI:1912598699
Name:MBK GASTRO LLC
Entity type:Organization
Organization Name:MBK GASTRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:KUKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-883-1176
Mailing Address - Street 1:763 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:770-883-1176
Mailing Address - Fax:678-985-1999
Practice Address - Street 1:763 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:770-883-1176
Practice Address - Fax:678-985-1999
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MBK GASTRO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-27
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty