Healthcare Provider Details

I. General information

NPI: 1376571752
Provider Name (Legal Business Name): PAUL EDWARD FUNDERBURK O.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6757 W NEWBERRY RD
GAINESVILLE FL
32605-4312
US

IV. Provider business mailing address

6757 W NEWBERRY RD
GAINESVILLE FL
32605-4312
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-2040
  • Fax: 352-331-1526
Mailing address:
  • Phone: 352-331-2040
  • Fax: 352-331-1526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number591711900
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: