Provider Demographics
NPI:1629384326
Name:FAULKNER, OLIVER
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2752 ZELDA RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2694
Mailing Address - Country:US
Mailing Address - Phone:334-271-4664
Mailing Address - Fax:334-271-4687
Practice Address - Street 1:2752 ZELDA RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2694
Practice Address - Country:US
Practice Address - Phone:334-271-4664
Practice Address - Fax:334-271-4687
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009948105Medicaid