Provider Demographics
NPI:1326023938
Name:FUNDERBURK, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:FUNDERBURK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1557 JANMAR RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5686
Mailing Address - Country:US
Mailing Address - Phone:678-344-8900
Mailing Address - Fax:678-666-5201
Practice Address - Street 1:1557 JANMAR RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5686
Practice Address - Country:US
Practice Address - Phone:678-344-8900
Practice Address - Fax:678-666-5201
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034138208800000X
GA34138208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000456332GMedicaid
GA000456332GMedicaid
E59649Medicare UPIN