Provider Demographics
NPI:1972777696
Name:FUNG, EDMOND (DC)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:
Last Name:FUNG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:EDMOND
Other - Middle Name:Y
Other - Last Name:FUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:415 N SAN MATEO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2493
Mailing Address - Country:US
Mailing Address - Phone:650-685-8883
Mailing Address - Fax:
Practice Address - Street 1:415 N SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2493
Practice Address - Country:US
Practice Address - Phone:650-685-8883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25236111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0252360OtherBLUE SHIELD
CAU69095Medicare UPIN
CADC0252360Medicare PIN