Provider Demographics
NPI:1992735641
Name:FAULKNER, LEE EDWIN (MD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:EDWIN
Last Name:FAULKNER
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 1:6005 PARK AVE STE 702
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5217
Mailing Address - Country:US
Mailing Address - Phone:901-682-7241
Mailing Address - Fax:901-682-7243
Practice Address - Street 1:6005 PARK AVE STE 702
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5217
Practice Address - Country:US
Practice Address - Phone:901-682-7241
Practice Address - Fax:901-682-7243
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000028255207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3803983Medicaid
TN1511392Medicaid
G30163Medicare UPIN