Provider Demographics
NPI:1851401020
Name:FUNNELL, THOMAS ROY (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ROY
Last Name:FUNNELL
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 1:1445 DONLON ST
Mailing Address - Street 2:#12
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5639
Mailing Address - Country:US
Mailing Address - Phone:805-642-3777
Mailing Address - Fax:805-644-9491
Practice Address - Street 1:1445 DONLON ST
Practice Address - Street 2:#12
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5639
Practice Address - Country:US
Practice Address - Phone:805-642-3777
Practice Address - Fax:805-644-9491
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 6924 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA576380382OtherVISION SERVICE PLAN
CASD0069240Medicaid
AR3159OtherMEDICAL EYE SERVICES
CAOP6924Medicare ID - Type Unspecified
CAT70155Medicare UPIN