Provider Demographics
NPI:1255382693
Name:FAULKNER, DOUGLAS HOWARD
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:HOWARD
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 1:17510 TALLY HO CT
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-1815
Mailing Address - Country:US
Mailing Address - Phone:813-920-0360
Mailing Address - Fax:813-920-0360
Practice Address - Street 1:17510 TALLY HO CT
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-1815
Practice Address - Country:US
Practice Address - Phone:813-920-0360
Practice Address - Fax:813-920-0360
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY350237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS0688ZMedicare ID - Type Unspecified