Provider Demographics
NPI:1790718120
Name:FAULKNER, KENDALL R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:R
Last Name:FAULKNER
Suffix:
Gender:F
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:PO BOX 631568
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6565 N CHARLES ST
Practice Address - Street 2:STE 209
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6800
Practice Address - Country:US
Practice Address - Phone:443-849-3184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD25643207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKJ15-39808203OtherCAREFIRST MARYLAND
MDS1380089OtherCAREFIRST REGIONAL
D76183Medicare UPIN
MDKJ15-39808203OtherCAREFIRST MARYLAND