Provider Demographics
NPI:1003875345
Name:FUNDERBURK, MARCIA WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:WAYNE
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3660
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:1255 LILA ST
Practice Address - Street 2:UFJP LEM TURNER FAMILY PRACTICE CENTER
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-3550
Practice Address - Country:US
Practice Address - Phone:904-244-5802
Practice Address - Fax:904-244-5791
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80070854Medicare PIN
FL07072ZMedicare PIN
FLD84931Medicare UPIN