Provider Demographics
NPI:1588851471
Name:KENNETH J. FUQUAY MD PA
Entity Type:Organization
Organization Name:KENNETH J. FUQUAY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:FUQUAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-745-6950
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
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062203207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1269Medicare PIN
FLF72626Medicare UPIN