NPIMap

Individual provider Active NPI

Brian Patrick Kuklok, DPM

  • Student in an Organized Health Care Education/Training Program
  • Portland, OR
National Provider Identifier
1205321882
Registry record updated Apr 8, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X
Practice address
1015 NW 22ND Ave
Portland, OR 97210-3025
Phone
(503) 413-8401
Fax
(503) 413-7361
NPI assigned
Jun 26, 2018
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Apr 8, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X Primary

Addresses

Primary practice location

1015 NW 22ND Ave
Portland, OR 97210-3025

Mailing address

1015 NW 22ND Ave
Portland, OR 97210-3025
Phone (503) 413-8401

Other practice location 1

3100 Telegraph Ave
Oakland, CA 94609-3239
Phone (800) 607-6377

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR, WA2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20220922001621 OR Practitioner - Podiatry 8426383159 Reassigns benefits to 1 organization
I20221109000279 WA Practitioner - Podiatry 8426383159 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Podiatry
Education
Other, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Legacy Salmon Creek HospitalGroup PAC ID 0446295711, 309 clinicians
Legacy Clinics LLCGroup PAC ID 0244144004, 714 clinicians

Practice addresses (Care Compare)

2101 NE 139TH St
Suite 260
Vancouver, WA 98686-2311
Phone (360) 487-2870

25050 SE Stark St
Suite 265
Gresham, OR 97030-3388
Phone (503) 674-2044

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
94.62 of 100Reported as apm
Quality
77.21
Promoting interoperability
99.06
Improvement activities
40

Procedures performed for Medicare patients

ProcedureNumber of procedures
Melanoma (skin cancer) excision1-10
Removal of tissue20
Removal of nail tissue12

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

Practice roles

OrganizationSpecialtyStatusNew patients
Legacy Clinics LLC CurrentSince Sep 8, 2022 Accepting new patients
Legacy Clinics LLC CurrentSince Sep 8, 2022 Accepting new patients
Legacy Salmon Creek Hospital CurrentSince Sep 8, 2022 Accepting new patients
Legacy Salmon Creek Hospital CurrentSince Sep 8, 2022 Accepting new patients
Legacy Emanuel Hospital & Health Center Past Accepting new patients

Locations

25050 SE Stark St
Ste 265
Gresham, OR 97030
Phone (503) 413-2005

25050 SE Stark St
Gresham, OR 97030
Phone (503) 413-5702

1015 NW 22nd Ave
Portland, OR 97210
Phone (503) 413-7582

1919 NW Lovejoy St
Portland, OR 97209
Phone (503) 415-5600

1130 NW 22nd Ave
Ste 220
Portland, OR 97210
Phone (503) 413-4134

2800 N Vancouver Ave
Ste 118
Portland, OR 97227
Phone (503) 249-8851

2211 NE 139th St
Vancouver, WA 98686
Phone (360) 397-1985

2101 NE 139th St
Ste 260
Vancouver, WA 98686
Phone (360) 487-2870

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 10

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1529971200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1554681600000",
    "number": "1205321882",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1015 NW 22ND AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972103025",
            "telephone_number": "503-413-8401",
            "fax_number": "503-413-7361"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1015 NW 22ND AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972103025",
            "telephone_number": "503-413-8401",
            "fax_number": "503-413-7361"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3100 Telegraph Ave",
            "address_purpose": "LOCATION",
            "city": "Oakland",
            "state": "CA",
            "postal_code": "946093239",
            "country_code": "US",
            "telephone_number": "800-607-6377",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KUKLOK",
        "first_name": "BRIAN",
        "middle_name": "PATRICK",
        "credential": "DPM",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2018-06-26",
        "last_updated": "2019-04-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

Verify at the official NPI Registry.