Provider Demographics
NPI:1376989467
Name:FAUNTLEROY, THOMAS JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:FAUNTLEROY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27809 WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-8123
Mailing Address - Country:US
Mailing Address - Phone:410-822-5088
Mailing Address - Fax:
Practice Address - Street 1:27809 WAVERLY RD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-8123
Practice Address - Country:US
Practice Address - Phone:410-822-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0015315207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease