Basic Information
| Provider Information | |||||||||
| NPI: | 1871887612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAULK | ||||||||
| FirstName: | ELISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBINSON | ||||||||
| OtherFirstName: | ELISA | ||||||||
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| OtherCredential: | DPM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O.BOX 331 | ||||||||
| Address2: | |||||||||
| City: | WAUCHULA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137602386 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 737 MAIN ST | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | LUMBERTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080483089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092679400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 08/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | #25MD00309700 | NJ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.