Provider Demographics
NPI:1780695148
Name:FAULKNER, ROBERT LEE JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
Last Name:FAULKNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4186 MILL ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014
Mailing Address - Country:US
Mailing Address - Phone:770-786-5345
Mailing Address - Fax:770-786-5348
Practice Address - Street 1:4186 MILL ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014
Practice Address - Country:US
Practice Address - Phone:770-786-5345
Practice Address - Fax:770-786-5348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA010715208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA010715OtherSTATE LICENSE
GA00010458AMedicaid
AF1133898OtherDEA
D90978Medicare UPIN
GA110715060AMedicare ID - Type Unspecified