Provider Demographics
NPI:1558369892
Name:FUNDERBURK, CHARLES HARWOOD JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HARWOOD
Last Name:FUNDERBURK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 BROADWAY EXT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7408
Mailing Address - Country:US
Mailing Address - Phone:405-230-9000
Mailing Address - Fax:405-230-9175
Practice Address - Street 1:9600 BROADWAY EXT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114
Practice Address - Country:US
Practice Address - Phone:405-230-9000
Practice Address - Fax:405-230-9157
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17610207X00000X, 207XX0005X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200040194OtherRAILROAD MEDICARE
OK100034390AMedicaid
F61010Medicare UPIN