=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770596256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID J FAULK MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 02/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1606 GLOUCESTER ST
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-7145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-265-7382
-----------------------------------------------------
Fax | 912-265-7383
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 ARTHUR J MOORE DR
-----------------------------------------------------
City | ST SIMONS ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31522-2238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-265-0644
-----------------------------------------------------
Fax | 912-265-7383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID J FAULK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 912-265-7382
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 039787
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------