Healthcare Provider Details

I. General information

NPI: 1013914068
Provider Name (Legal Business Name): TODD E FUNK O.D., F.A.A.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HILLCREST DR STE B
WASHINGTON IL
61571-2227
US

IV. Provider business mailing address

100 HILLCREST DR
WASHINGTON IL
61571-2200
US

V. Phone/Fax

Practice location:
  • Phone: 309-444-5188
  • Fax: 309-444-2258
Mailing address:
  • Phone: 309-444-5188
  • Fax: 309-444-2258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008264
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: