Healthcare Provider Details

I. General information

NPI: 1366429649
Provider Name (Legal Business Name): CHARLES TED PAULK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WESTGATE PKWY
DOTHAN AL
36303
US

IV. Provider business mailing address

1245 WESTGATE PKWY
DOTHAN AL
36303
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-9595
  • Fax: 334-793-1578
Mailing address:
  • Phone: 334-793-9595
  • Fax: 334-793-1578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6629
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: