Provider Demographics
NPI:1164519849
Name:FUNKHOUSER, BARRY L (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:L
Last Name:FUNKHOUSER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 VIXEN CT
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-9353
Mailing Address - Country:US
Mailing Address - Phone:334-699-8516
Mailing Address - Fax:
Practice Address - Street 1:301 ANDREWS AVENUE
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7387
Practice Address - Fax:334-255-7716
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL928103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical