Provider Demographics
NPI:1164185583
Name:FUNK, BRANDON (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:FUNK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 MISSOURI ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3236
Mailing Address - Country:US
Mailing Address - Phone:858-750-0719
Mailing Address - Fax:
Practice Address - Street 1:1626 SWEETWATER RD STE AB
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-7645
Practice Address - Country:US
Practice Address - Phone:619-474-5916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300705208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty