MEDICARE: DR. PHILIP BURTON FUNDERBURK OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	922	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093830135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP BURTON FUNDERBURK OD

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD
Second Line	:	520
City	:	VIENNA
State	:	VA
Zip	:	22182-3990
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	703-991-0514

Provider Business Practice Location Address
First Line	:	7749 MATTHEWS MINT HILL RD
Second Line	:
City	:	MINT HILL
State	:	NC
Zip	:	28227-7598
Country	:	US
Telephone Number	:	704-545-9797
Fax Number	:	704-545-3111

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	11/14/2017

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