Provider Demographics
NPI:1619938644
Name:FUNK, KEVIN ANDRE (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDRE
Last Name:FUNK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 SAINT JOHNS AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6859
Mailing Address - Country:US
Mailing Address - Phone:386-530-5640
Mailing Address - Fax:
Practice Address - Street 1:6100 SAINT JOHNS AVE STE 5
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6859
Practice Address - Country:US
Practice Address - Phone:386-530-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3473207P00000X, 207Q00000X
FLME144992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD39120Medicare UPIN