Healthcare Provider Details

I. General information

NPI: 1972647386
Provider Name (Legal Business Name): MICHAEL FUNG MBCHB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 MAIN ST 160 FARBER HALL
BUFFALO NY
14214-3001
US

IV. Provider business mailing address

95 SPRING MEADOW DR APT 19
WILLIAMSVILLE NY
14221-8415
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-2070
  • Fax:
Mailing address:
  • Phone: 716-632-6002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number002696-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: