Provider Demographics
NPI:1558332387
Name:KANUCK, DAVID M (D P M PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:KANUCK
Suffix:
Gender:M
Credentials:D P M PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8851 BOARDROOM CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4888
Mailing Address - Country:US
Mailing Address - Phone:239-481-7000
Mailing Address - Fax:239-481-8150
Practice Address - Street 1:18308 MURDOCK CIR
Practice Address - Street 2:STE 102
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1025
Practice Address - Country:US
Practice Address - Phone:239-481-7000
Practice Address - Fax:239-481-8150
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPO3295213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO3295OtherLICENSE
FL14-1989478OtherTAX ID
FLP00630109OtherRAILROAD MEDICARE
FLPO3295OtherLICENSE