Provider Demographics
NPI:1750512414
Name:CONRAD FAULKNER OD PA
Entity Type:Organization
Organization Name:CONRAD FAULKNER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-566-4583
Mailing Address - Street 1:7395 US HIGHWAY 70 W
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551-8211
Mailing Address - Country:US
Mailing Address - Phone:252-566-4583
Mailing Address - Fax:
Practice Address - Street 1:834 HARDEE RD
Practice Address - Street 2:VERNON PARK MALL
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-3360
Practice Address - Country:US
Practice Address - Phone:252-559-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09271OtherBCBS
246158OtherMEDICARE ID- TYPE UNSPECIFIED
T64717Medicare UPIN