Provider Demographics
NPI:1467568519
Name:SAM R. FUNK, O.D., P.A.
Entity Type:Organization
Organization Name:SAM R. FUNK, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:785-462-3348
Mailing Address - Street 1:505 N FRANKLIN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:COLBY
Mailing Address - State:KS
Mailing Address - Zip Code:67701-2342
Mailing Address - Country:US
Mailing Address - Phone:785-462-3348
Mailing Address - Fax:785-462-3599
Practice Address - Street 1:505 N FRANKLIN AVE STE B
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:KS
Practice Address - Zip Code:67701-2342
Practice Address - Country:US
Practice Address - Phone:785-462-3348
Practice Address - Fax:785-462-3599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11113152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12589230OtherCAQH
KS201083380AMedicaid
KS100090170AMedicaid
KS656990OtherFIRST GUARD
KS005149OtherBC/BS
001269OtherBCBS
T43673Medicare UPIN
KS0656400001Medicare NSC