Provider Demographics
NPI:1992379531
Name:FUNNAMARK, RANDALL LEE JR (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LEE
Last Name:FUNNAMARK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10381 PERDIDO ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-5671
Mailing Address - Country:US
Mailing Address - Phone:714-743-8223
Mailing Address - Fax:
Practice Address - Street 1:620 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4119
Practice Address - Country:US
Practice Address - Phone:702-388-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL1722207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine