Provider Demographics
NPI:1083615850
Name:FUNG, AUDREY S (OD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:S
Last Name:FUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-3851
Mailing Address - Country:US
Mailing Address - Phone:203-596-0406
Mailing Address - Fax:203-756-7316
Practice Address - Street 1:3600 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-3851
Practice Address - Country:US
Practice Address - Phone:203-596-0406
Practice Address - Fax:203-756-7316
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2010-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004249951Medicaid
CT004249951Medicaid
V05170Medicare UPIN