Healthcare Provider Details

I. General information

NPI: 1588836126
Provider Name (Legal Business Name): CHRISTOPHER EDWARD FUNDAKOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CHESTNUT ST FL 6
PHILADELPHIA PA
19107
US

IV. Provider business mailing address

925 CHESTNUT ST FL 6
PHILADELPHIA PA
19107-4204
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6784
  • Fax: 215-923-4532
Mailing address:
  • Phone: 215-955-6784
  • Fax: 215-923-4532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD49551
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD451417
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: