MEDICARE: KELLY R KUNKEL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	H2520	TX

General Provider Information

NPI Number	:	1730144502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY R KUNKEL M.D.

Provider Business Mailing Address
First Line	:	1830 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1391
Country	:	US
Telephone Number	:	817-335-5200
Fax Number	:	817-923-0780

Provider Business Practice Location Address
First Line	:	1830 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1391
Country	:	US
Telephone Number	:	817-335-5200
Fax Number	:	817-923-0780

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	07/08/2007

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