Provider Demographics
NPI:1114919370
Name:FUNDERBURK MOCK, AMY ELISE (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELISE
Last Name:FUNDERBURK MOCK
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 770390
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38177-0390
Mailing Address - Country:US
Mailing Address - Phone:901-844-1431
Mailing Address - Fax:
Practice Address - Street 1:4100 AUSTIN PEAY HWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2502
Practice Address - Country:US
Practice Address - Phone:901-844-1431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD31772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3843367Medicaid
TN3843367Medicaid
TN3843367Medicare ID - Type UnspecifiedCIGNA MEDICARE TN