Provider Demographics
NPI:1104883966
Name:FUNDERBURK, JASON GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:GLEN
Last Name:FUNDERBURK
Suffix:
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 1:116 CONCORD RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2940
Mailing Address - Country:US
Mailing Address - Phone:865-777-6880
Mailing Address - Fax:
Practice Address - Street 1:116 CONCORD RD
Practice Address - Street 2:SUITE 500
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2940
Practice Address - Country:US
Practice Address - Phone:865-777-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 930652085R0204X
TN471532085R0204X
MI43011021622085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology