Basic Information
| Provider Information | |||||||||
| NPI: | 1265498109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUNKHOUSER | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 905 | ||||||||
| Address2: | |||||||||
| City: | FALMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025410905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085488989 | ||||||||
| FaxNumber: | 5085485789 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 BRAMBLE BUSH DR | ||||||||
| Address2: | |||||||||
| City: | FALMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025402325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085486563 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 32735 | MA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2092468 | 05 | MA | MEDICAID | 27001 | 01 | MA | HARVARD PILGRIM | OTHER | 795473 | 01 | MA | TUFTS HEALTH | OTHER | L07149 | 01 | BLUE CROSS | OTHER |