Provider Demographics
NPI:1730293770
Name:FUNK, TINA M (OD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:M
Last Name:FUNK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:CONNOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 773
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-0773
Mailing Address - Country:US
Mailing Address - Phone:618-395-5222
Mailing Address - Fax:618-395-8552
Practice Address - Street 1:1200 N EAST ST
Practice Address - Street 2:STE. 2
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2499
Practice Address - Country:US
Practice Address - Phone:618-395-5222
Practice Address - Fax:618-395-8552
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009641Medicaid
P00174010OtherRAILROAD MEDICARE
IL098727OtherHEALTH ALLIANCE
IL669964OtherHEALTHLINK
IL294490001Medicare PIN
IL098727OtherHEALTH ALLIANCE