Provider Demographics
NPI:1326031568
Name:FUNK, THOMAS MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:FUNK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-8895
Mailing Address - Country:US
Mailing Address - Phone:317-881-3937
Mailing Address - Fax:317-887-4008
Practice Address - Street 1:30 N EMERSON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8895
Practice Address - Country:US
Practice Address - Phone:317-881-3937
Practice Address - Fax:317-887-4008
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002077A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN154538OtherCOLE VISION
IN0005444107OtherAETNA
IN000000015215OtherMPLAN
IN000000214774OtherBCBS
IN000000214774OtherBCBS
IN154538OtherCOLE VISION