Provider Demographics
NPI:1548287196
Name:FUNKHOUSER, LESLIE M (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:M
Last Name:FUNKHOUSER
Suffix:
Gender:M
Credentials:OPTICIAN
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 952
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-0952
Mailing Address - Country:US
Mailing Address - Phone:903-677-1985
Mailing Address - Fax:903-677-2099
Practice Address - Street 1:1260 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3619
Practice Address - Country:US
Practice Address - Phone:903-677-1985
Practice Address - Fax:903-677-2099
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4315180001Medicare ID - Type Unspecified