Provider Demographics
NPI:1518923549
Name:FAULK, CARLTON TRENT (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:MR
First Name:CARLTON
Middle Name:TRENT
Last Name:FAULK
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 INTERSTATE SOUTH DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143
Mailing Address - Country:US
Mailing Address - Phone:706-253-3376
Mailing Address - Fax:706-253-3223
Practice Address - Street 1:150 INTERSTATE SOUTH DR
Practice Address - Street 2:SUITE 100
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143
Practice Address - Country:US
Practice Address - Phone:706-253-3376
Practice Address - Fax:706-253-3223
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA033322207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA07BBSJSMedicare ID - Type Unspecified
F55640Medicare UPIN