Provider Demographics
NPI:1093786022
Name:FUNAMURA, JANWYN LOY (MD)
Entity Type:Individual
Prefix:DR
First Name:JANWYN
Middle Name:LOY
Last Name:FUNAMURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JANWYN
Other - Middle Name:COLEEN
Other - Last Name:FUNAMURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5804 E ACORN CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-2618
Mailing Address - Country:US
Mailing Address - Phone:209-931-6121
Mailing Address - Fax:209-931-4486
Practice Address - Street 1:2320 N CALIFORNIA ST
Practice Address - Street 2:SUITE 2
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5509
Practice Address - Country:US
Practice Address - Phone:209-953-3705
Practice Address - Fax:209-953-3700
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35135208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76496ZMedicaid
CAD47096Medicare UPIN