Basic Information
| Provider Information | |||||||||
| NPI: | 1659630895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNCHES | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154561825 | ||||||||
| FaxNumber: | 2154561825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1602 E WADSWORTH AVE # 4 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191501004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157539438 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2012 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA10155100 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD455675 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103046777 | 05 | PA | MEDICAID |