Provider Demographics
NPI:1831126911
Name:KUNGLE, JENNIFER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:KUNGLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 DORSEY HALL DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7711
Mailing Address - Country:US
Mailing Address - Phone:410-730-8878
Mailing Address - Fax:410-997-8282
Practice Address - Street 1:5012 DORSEY HALL DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7711
Practice Address - Country:US
Practice Address - Phone:410-730-8878
Practice Address - Fax:410-997-8282
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5700600001Medicare NSC
MDU95698Medicare UPIN
MD617M102FMedicare ID - Type Unspecified