Provider Demographics
NPI:1770560724
Name:FAULL, TED (MD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:FAULL
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 1:7341 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5900
Mailing Address - Country:US
Mailing Address - Phone:330-729-8977
Mailing Address - Fax:330-729-8959
Practice Address - Street 1:900 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5007
Practice Address - Country:US
Practice Address - Phone:330-726-2575
Practice Address - Fax:330-921-9319
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36082109207Q00000X
OH35.091967207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2890359Medicaid
OH2890359Medicaid
OH4249062Medicare PIN