Basic Information
| Provider Information | |||||||||
| NPI: | 1891724076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUNKLE | ||||||||
| FirstName: | HERBERT | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3600 ROUTE 66 FL 3 | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077532605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328070877 | ||||||||
| FaxNumber: | 2017511680 | ||||||||
| Practice Location | |||||||||
| Address1: | 1173 BEACON AVE | ||||||||
| Address2: | |||||||||
| City: | MANAHAWKIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080502420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092504104 | ||||||||
| FaxNumber: | 6099784860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD024230E | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 25MA04816000 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 270411 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001282404 | 05 | PA | MEDICAID | 03658835 | 05 | NY | MEDICAID |