Provider Demographics
NPI:1700874260
Name:KENNEDY-FUNTILA, BARBARA (MD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:KENNEDY-FUNTILA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1541 FLORIDA AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4429
Mailing Address - Country:US
Mailing Address - Phone:209-577-3388
Mailing Address - Fax:209-523-0764
Practice Address - Street 1:1541 FLORIDA AVE
Practice Address - Street 2:STE 200
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4429
Practice Address - Country:US
Practice Address - Phone:209-577-3388
Practice Address - Fax:209-523-0764
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD069AOtherGROUP PTAN
CACD231ZOtherINDIVIDUAL PTAN
CA110167145OtherRAILROAD MEDICARE
CAZZZ48224ZOtherMEDICARE IDENTIFICATION #
CACD231ZOtherINDIVIDUAL PTAN