Provider Demographics
NPI:1902227424
Name:KELLY R. KUNKEL, M.D., P.A.
Entity Type:Organization
Organization Name:KELLY R. KUNKEL, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:KUNKEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-335-5200
Mailing Address - Street 1:1830 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1391
Mailing Address - Country:US
Mailing Address - Phone:817-335-5200
Mailing Address - Fax:817-923-0780
Practice Address - Street 1:1830 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1391
Practice Address - Country:US
Practice Address - Phone:817-335-5200
Practice Address - Fax:817-923-0780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208650122X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0025AAOtherMEDICARE IDENTIFICATION NUMBER