Provider Demographics
NPI:1871857862
Name:KUNTZ, DERRICK JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:JAY
Last Name:KUNTZ
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 1:890 LAZELLE ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-1611
Mailing Address - Country:US
Mailing Address - Phone:605-720-2600
Mailing Address - Fax:605-720-2609
Practice Address - Street 1:502 E MONROE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1400
Practice Address - Country:US
Practice Address - Phone:605-755-4060
Practice Address - Fax:605-755-4012
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine