Healthcare Provider Details

I. General information

NPI: 1902227424
Provider Name (Legal Business Name): KELLY R. KUNKEL, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 8TH AVE
FORT WORTH TX
76110-1391
US

IV. Provider business mailing address

1830 8TH AVE
FORT WORTH TX
76110-1391
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-5200
  • Fax: 817-923-0780
Mailing address:
  • Phone: 817-335-5200
  • Fax: 817-923-0780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number208650122X
License Number StateTX

VIII. Authorized Official

Name: DR. KELLY RAYMOND KUNKEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 817-335-5200