Healthcare Provider Details

I. General information

NPI: 1679420012
Provider Name (Legal Business Name): CHARLES EDWARD FAULK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BELLE TERRE PKWY STE 112
PALM COAST FL
32164-2315
US

IV. Provider business mailing address

800 BELLE TERRE PKWY STE 112
PALM COAST FL
32164-2315
US

V. Phone/Fax

Practice location:
  • Phone: 386-777-7311
  • Fax:
Mailing address:
  • Phone: 386-777-7311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO4791
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: