Healthcare Provider Details

I. General information

NPI: 1891776191
Provider Name (Legal Business Name): SHAUN MICHAEL KUNISAKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

9910 FRANKLIN SQUARE DR STE 2110
BALTIMORE MD
21236-4902
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-6256
  • Fax: 410-502-5314
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number217767
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301092951
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number4301092951
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberD86445
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: