MEDICARE: DONALD JOSEPH FAULKNER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	MD00024786	WA
2	208600000X	Surgery Physician	01068190	IN

General Provider Information

NPI Number	:	1609893312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD JOSEPH FAULKNER M.D.

Provider Business Mailing Address
First Line	:	707 E CEDAR ST
Second Line	:	STE 200
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-2057
Country	:	US
Telephone Number	:	574-335-8700
Fax Number	:	574-335-0760

Provider Business Practice Location Address
First Line	:	1919 LAKE AVE STE 102
Second Line	:	STE 102
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-7830
Country	:	US
Telephone Number	:	574-948-5170
Fax Number	:	574-948-5498

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	05/28/2020

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