Provider Demographics
NPI:1225095599
Name:FUQUAY, KENNETH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:FUQUAY
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 1:210 JUPITER LAKES BLVD
Mailing Address - Street 2:BLDG 3000 SUITE 103
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7191
Mailing Address - Country:US
Mailing Address - Phone:561-745-6950
Mailing Address - Fax:561-748-1806
Practice Address - Street 1:210 JUPITER LAKES BLVD
Practice Address - Street 2:BLDG 3000 SUITE 103
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7191
Practice Address - Country:US
Practice Address - Phone:561-745-6950
Practice Address - Fax:561-748-1806
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062203207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250896600Medicaid
FL000K1269Medicare ID - Type UnspecifiedGROUP
FLF72626Medicare UPIN
FL26107CMedicare ID - Type UnspecifiedINDIVIDUAL