Provider Demographics
NPI:1982807392
Name:BUNNING, KENNETH R (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:BUNNING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3714 GUARDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2974
Mailing Address - Country:US
Mailing Address - Phone:222-247-2101
Mailing Address - Fax:252-247-4675
Practice Address - Street 1:3714 GUARDIAN AVE
Practice Address - Street 2:SUITE E
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2974
Practice Address - Country:US
Practice Address - Phone:252-247-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9814208800000X
NC2011-01863208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94655OtherBCBS
FL279031900Medicaid
FL117472OtherOPERATING ENGINEERS
FL344465OtherAVMED
FLP00468955OtherRAILROAD MEDICARE
FL7137932OtherAETNA PROVIDER #
FL7137932OtherAETNA PROVIDER #