Provider Demographics
NPI:1609893312
Name:FAULKNER, DONALD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:JOSEPH
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSEPH
Other - Middle Name:
Other - Last Name:FAULKNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:1919 LAKE AVE STE 102
Practice Address - Street 2:STE 102
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7830
Practice Address - Country:US
Practice Address - Phone:574-948-5170
Practice Address - Fax:574-948-5498
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024786208600000X
IN01068190208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000668717OtherBCBS
IN200989700Medicaid
INP00962856Medicare PIN
IN200989700Medicaid