Provider Demographics
NPI:1265487870
Name:FUNG, PAK K (MD)
Entity Type:Individual
Prefix:DR
First Name:PAK
Middle Name:K
Last Name:FUNG
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 1:110 HALEIGH DRIVE
Mailing Address - Street 2:
Mailing Address - City:ENERGY
Mailing Address - State:IL
Mailing Address - Zip Code:62933
Mailing Address - Country:US
Mailing Address - Phone:618-727-3864
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-079290207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079290-3Medicaid
IL036079290-6Medicaid
KY7100150560Medicaid
IL036079290Medicaid
IL3932056OtherBLUE SHIELD
IL036079290-6Medicaid
DE7181Medicare PIN
K27909Medicare PIN
E30866Medicare UPIN
IL036079290-3Medicaid
KY7100150560Medicaid
IL214881004Medicare PIN