Healthcare Provider Details

I. General information

NPI: 1326015173
Provider Name (Legal Business Name): TODD FUNKHOUSER M.D., PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 E LOHMAN AVE SUITE A
LAS CRUCES NM
88011-8273
US

IV. Provider business mailing address

3800 E LOHMAN AVE SUITE A
LAS CRUCES NM
88011-8273
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-6500
  • Fax: 575-522-0591
Mailing address:
  • Phone: 575-522-6500
  • Fax: 575-522-0591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberL4382
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMD2009-0308
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberL4382
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: