Healthcare Provider Details

I. General information

NPI: 1619292653
Provider Name (Legal Business Name): MR. DAVID ALLEN FAULKNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 N WYATT DR
EL DORADO AR
71730-4189
US

IV. Provider business mailing address

3025 N WYATT DR
EL DORADO AR
71730-4189
US

V. Phone/Fax

Practice location:
  • Phone: 870-862-8057
  • Fax:
Mailing address:
  • Phone: 870-862-8057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: