Provider Demographics
NPI:1326493289
Name:FUNK, BLAIR L (MD)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:L
Last Name:FUNK
Suffix:
Gender:F
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:PO BOX 746724
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6724
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:103 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-7603
Practice Address - Country:US
Practice Address - Phone:910-400-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58464207Q00000X
WAMD61422193207Q00000X
NC2024-01311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine