Provider Demographics
NPI:1174866180
Name:KUNKEL, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:KUNKEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 DEER RUN TRL
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:CT
Mailing Address - Zip Code:06784-2032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 DEER RUN TRL
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:CT
Practice Address - Zip Code:06784-2032
Practice Address - Country:US
Practice Address - Phone:860-355-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK9253509OtherDEA