Provider Demographics
NPI:1871887612
Name:FAULK, ELISA (DPM)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:FAULK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:P.O.BOX 331
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873
Mailing Address - Country:US
Mailing Address - Phone:813-760-2386
Mailing Address - Fax:
Practice Address - Street 1:737 MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-3089
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ#25MD00309700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist