Provider Demographics
NPI:1760475271
Name:FAULK, DAVID L (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:FAULK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E COUNTYLINE RD
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-2178
Mailing Address - Country:US
Mailing Address - Phone:815-786-2722
Mailing Address - Fax:815-786-6840
Practice Address - Street 1:1 E COUNTYLINE RD
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-2178
Practice Address - Country:US
Practice Address - Phone:815-786-2722
Practice Address - Fax:815-786-6840
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 049209208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1921614OtherBC/BS
IL036049209Medicaid
IL036049209Medicaid
IL215010003Medicare PIN
C37149Medicare UPIN