Provider Demographics
NPI:1912050527
Name:KUNKEL, BETH (OD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:KUNKEL
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 1:215 RICHARD A MAUTINO DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1144
Mailing Address - Country:US
Mailing Address - Phone:815-664-5331
Mailing Address - Fax:815-663-5057
Practice Address - Street 1:215 RICHARD A MAUTINO DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1144
Practice Address - Country:US
Practice Address - Phone:815-664-5331
Practice Address - Fax:815-663-5057
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008410152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU23663Medicare UPIN
IL410049036Medicare PIN
ILL94687Medicare PIN