Provider Demographics
NPI:1043715030
Name:FAULKNER, JUSTIN DANIEL (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DANIEL
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 1:2739 IRON GATE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-3731
Mailing Address - Country:US
Mailing Address - Phone:910-763-7363
Mailing Address - Fax:
Practice Address - Street 1:2739 IRON GATE DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-3731
Practice Address - Country:US
Practice Address - Phone:910-763-7363
Practice Address - Fax:910-251-8296
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-00111208600000X
KS0447750208600000X
MO2023022425208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery