Provider Demographics
NPI:1376571752
Name:FUNDERBURK, PAUL EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EDWARD
Last Name:FUNDERBURK
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 1:6757 W NEWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4312
Mailing Address - Country:US
Mailing Address - Phone:352-331-2040
Mailing Address - Fax:352-331-1526
Practice Address - Street 1:6757 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4312
Practice Address - Country:US
Practice Address - Phone:352-331-2040
Practice Address - Fax:352-331-1526
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL591711900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1269OtherFLA LIC NUMBER
591711900OtherTAX ID
FL084871900Medicaid
FL084871900Medicaid