Provider Demographics
NPI:1033179882
Name:FAULK, ELIZABETH ANNE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:FAULK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-3382
Mailing Address - Country:US
Mailing Address - Phone:925-482-8249
Mailing Address - Fax:925-482-2834
Practice Address - Street 1:1375 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3382
Practice Address - Country:US
Practice Address - Phone:925-482-8249
Practice Address - Fax:925-482-2834
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26815207P00000X
CAC54851207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ435075Medicaid
73736Medicare ID - Type Unspecified
F67771Medicare UPIN
Z114374Medicare PIN