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General NPI Number Information
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NPI Number | 1003875345
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Entity Type | Individual
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Provider Name | MARCIA WAYNE FUNDERBURK M.D.
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Gender | Female
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Dates
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Enumeration Date | 03/23/2006
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Last Update Date | 12/02/2007
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Provider Practice Location Address
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Address Line | 1255 LILA ST UFJP LEM TURNER FAMILY PRACTICE CENTER
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City | JACKSONVILLE
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State | FL
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Zip | 32208-3550
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Country | US
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Telephone | 904-244-5802
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Fax | 904-244-5791
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Provider Business Mailing Address
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Address Line | PO BOX 44008 UFJP PROVIDER ENROLLMENT
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City | JACKSONVILLE
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State | FL
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Zip | 32231-4008
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Country | US
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Telephone | 904-244-3660
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Fax | 904-244-3425
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME51523
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License Number State | FL
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