Healthcare Provider Details

I. General information

NPI: 1700836525
Provider Name (Legal Business Name): JACK E PAULK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 SE 18TH AVE BLDG 300
OCALA FL
34471-8215
US

IV. Provider business mailing address

12109 CR 103
OXFORD FL
34484-2967
US

V. Phone/Fax

Practice location:
  • Phone: 352-351-1313
  • Fax: 352-351-1927
Mailing address:
  • Phone: 352-391-6494
  • Fax: 352-391-6498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME34723
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: