Provider Demographics
NPI:1093830135
Name:FUNDERBURK, PHILIP BURTON (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:BURTON
Last Name:FUNDERBURK
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:7749 MATTHEWS MINT HILL RD
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-7598
Practice Address - Country:US
Practice Address - Phone:704-545-9797
Practice Address - Fax:704-545-3111
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC922152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909297Medicaid
NC246250Medicare ID - Type Unspecified
NC8909297Medicaid