Healthcare Provider Details

I. General information

NPI: 1932128121
Provider Name (Legal Business Name): MARK PAULEKAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 S FAIRMONT AVE
LODI CA
95240-5118
US

IV. Provider business mailing address

3304 MOKELUMNE CT
MODESTO CA
95354-2176
US

V. Phone/Fax

Practice location:
  • Phone: 209-339-7575
  • Fax:
Mailing address:
  • Phone: 209-524-5127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA43159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: