Healthcare Provider Details

I. General information

NPI: 1679510184
Provider Name (Legal Business Name): PHILIP PAULK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 POINCIANA AVE
MAMOU LA
70554-2243
US

IV. Provider business mailing address

200 CORPORATE BLVD SUITE 201
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 225-803-6707
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number199960
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: