Provider Demographics
NPI:1417914789
Name:FUNKHOUSER, CALVIN A (DO)
Entity Type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:A
Last Name:FUNKHOUSER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CROATAN RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2617
Mailing Address - Country:US
Mailing Address - Phone:540-421-5557
Mailing Address - Fax:
Practice Address - Street 1:500 J CLYDE MORRIS BLVD DEPT OF
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-612-7200
Practice Address - Fax:757-594-3184
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001910363A00000X
VA0116035964390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010117801Medicaid
VAP00263494OtherRAILROAD MEDICARE
VAP00263494OtherRAILROAD MEDICARE
VA010117801Medicaid
VAMC12272Medicare PIN