Healthcare Provider Details

I. General information

NPI: 1538166574
Provider Name (Legal Business Name): JEFFREY ALAN KUNKES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 UPPER RIVERDALE RD SW SUITE 10
RIVERDALE GA
30274-2626
US

IV. Provider business mailing address

33 UPPER RIVERDALE RD SW SUITE 10
RIVERDALE GA
30274
US

V. Phone/Fax

Practice location:
  • Phone: 678-902-0222
  • Fax: 678-902-0226
Mailing address:
  • Phone: 678-902-0222
  • Fax: 678-902-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number021535
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number021535
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: