Provider Demographics
NPI:1285910786
Name:FAULK, MARIA ALEJANDRA (OD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ALEJANDRA
Last Name:FAULK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 ETHAN LN
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-4116
Mailing Address - Country:US
Mailing Address - Phone:919-749-9891
Mailing Address - Fax:
Practice Address - Street 1:9820 CALLABRIDGE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-7669
Practice Address - Country:US
Practice Address - Phone:704-394-3886
Practice Address - Fax:704-392-3699
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002471152W00000X
NC2255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920812Medicaid
NC5920812Medicaid