Basic Information
Provider Information | |||||||||
NPI: | 1326179680 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FUNK | ||||||||
FirstName: | DORY | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 10100 | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | CO | ||||||||
PostalCode: | 814160008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708747668 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1450 BURGESS ST | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | CO | ||||||||
PostalCode: | 814162849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708747668 | ||||||||
FaxNumber: | 9708740708 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2007 | ||||||||
LastUpdateDate: | 09/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32321 | CO | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X | 32321 | CO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 01323211 | 05 | CO |   | MEDICAID |