Healthcare Provider Details

I. General information

NPI: 1326031568
Provider Name (Legal Business Name): THOMAS MICHAEL FUNK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N EMERSON AVE
GREENWOOD IN
46143-8895
US

IV. Provider business mailing address

30 N EMERSON AVE
GREENWOOD IN
46143-8895
US

V. Phone/Fax

Practice location:
  • Phone: 317-881-3937
  • Fax: 317-887-4008
Mailing address:
  • Phone: 317-881-3937
  • Fax: 317-887-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002077A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: