Provider Demographics
NPI:1023000676
Name:FAULK, KELLIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:A
Last Name:FAULK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLIE
Other - Middle Name:L OR LELEUX
Other - Last Name:FAULK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-659-8703
Mailing Address - Fax:336-659-8704
Practice Address - Street 1:1400 WESTGATE CENTER DRIVE
Practice Address - Street 2:SUITE 130
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3104
Practice Address - Country:US
Practice Address - Phone:336-659-8703
Practice Address - Fax:336-659-8704
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601607207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891003PMedicaid
NC891003PMedicaid
NCG38519Medicare UPIN
460001353Medicare PIN