Healthcare Provider Details

I. General information

NPI: 1821664277
Provider Name (Legal Business Name): JOHN PAUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 5TH ST
RAPID CITY SD
57701-7350
US

IV. Provider business mailing address

2905 5TH ST
RAPID CITY SD
57701-7350
US

V. Phone/Fax

Practice location:
  • Phone: 605-341-7337
  • Fax:
Mailing address:
  • Phone: 605-341-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15523
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: