Healthcare Provider Details

I. General information

NPI: 1942307962
Provider Name (Legal Business Name): GORDON FAULKNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 E BLUE MOUNDS RD
MOUNT HOREB WI
53572-2634
US

IV. Provider business mailing address

2002 E BLUE MOUNDS RD
MOUNT HOREB WI
53572-2634
US

V. Phone/Fax

Practice location:
  • Phone: 608-274-9717
  • Fax:
Mailing address:
  • Phone: 608-274-9717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22351
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: