Provider Demographics
NPI:1386822310
Name:FAULCONER, RENEE MANSFIELD (OD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MANSFIELD
Last Name:FAULCONER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-6968
Mailing Address - Country:US
Mailing Address - Phone:903-595-8977
Mailing Address - Fax:
Practice Address - Street 1:4824 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1312
Practice Address - Country:US
Practice Address - Phone:903-581-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4997-TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist