Provider Demographics
NPI:1023045796
Name:FUNNELL, JOHN WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALTER
Last Name:FUNNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 MANHATTAN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5120
Mailing Address - Country:US
Mailing Address - Phone:310-545-4585
Mailing Address - Fax:
Practice Address - Street 1:946 MANHATTAN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5120
Practice Address - Country:US
Practice Address - Phone:310-545-4585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06029T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP6029BMedicare ID - Type Unspecified
CAU22737Medicare UPIN