MEDICARE: TONI FUNICELLA M.D.

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	174400000X	Specialist	D9447	TX
2	207N00000X	Dermatology Physician	D9447	TX

General Provider Information

NPI Number	:	1205830106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONI FUNICELLA M.D.

Provider Business Mailing Address
First Line	:	13740 RESEARCH BLVD
Second Line	:	STE P4
City	:	AUSTIN
State	:	TX
Zip	:	78750-1835
Country	:	US
Telephone Number	:	512-250-5521
Fax Number	:	512-250-2291

Provider Business Practice Location Address
First Line	:	13740 RESEARCH BLVD
Second Line	:	STE P4
City	:	AUSTIN
State	:	TX
Zip	:	78750-1835
Country	:	US
Telephone Number	:	512-250-5521
Fax Number	:	512-250-2291

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	02/07/2008

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