Healthcare Provider Details

I. General information

NPI: 1750372405
Provider Name (Legal Business Name): DOUGLAS GORDON PAULK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17375 HALL RD
MACOMB TOWNSHIP MI
48044-4060
US

IV. Provider business mailing address

17375 HALL RD
MACOMB TOWNSHIP MI
48044-4060
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-0550
  • Fax: 586-228-8125
Mailing address:
  • Phone: 586-228-0550
  • Fax: 586-228-8125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101007995
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: