Healthcare Provider Details

I. General information

NPI: 1013531367
Provider Name (Legal Business Name): MATT DONALD PAULSON R.T.(R)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 DAUPHIN ST
MOBILE AL
36608-1753
US

IV. Provider business mailing address

5909 CANSLER DR
MOBILE AL
36609-7023
US

V. Phone/Fax

Practice location:
  • Phone: 251-344-9630
  • Fax:
Mailing address:
  • Phone: 256-604-3773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number588323
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: