Provider Demographics
NPI:1184776791
Name:FUNK, JONATHAN ROY (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROY
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 1:970 E WASHINGTON ST
Mailing Address - Street 2:#5F
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256
Mailing Address - Country:US
Mailing Address - Phone:330-725-5282
Mailing Address - Fax:
Practice Address - Street 1:970 E WASHINGTON ST
Practice Address - Street 2:#5F
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256
Practice Address - Country:US
Practice Address - Phone:330-725-5282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062239207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0986803Medicaid
F89249Medicare UPIN
OH7422551Medicare PIN
OH0986803Medicaid