Provider Demographics
NPI:1821298985
Name:KUNBERGER, JACK DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DAVID
Last Name:KUNBERGER
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5110 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5720
Practice Address - Country:US
Practice Address - Phone:260-469-6605
Practice Address - Fax:260-969-3066
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068425A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000666601OtherANTHEM
IN200986220Medicaid
IN000000666587OtherANTHEM
INM400017531Medicare PIN
IN000000666587OtherANTHEM