1558332387 NPI number — DAVID M KANUCK D P M PA

Table of content: DAVID M KANUCK D P M PA (NPI 1558332387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558332387 NPI number — DAVID M KANUCK D P M PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KANUCK
Provider First Name:
DAVID
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D P M PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558332387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8851 BOARDROOM CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33919-4888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-481-7000
Provider Business Mailing Address Fax Number:
239-481-8150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18308 MURDOCK CIR
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33948-1025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-481-7000
Provider Business Practice Location Address Fax Number:
239-481-8150
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO3295 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PO3295 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 14-1989478 . This is a "TAX ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00630109 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 006849900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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