Healthcare Provider Details

I. General information

NPI: 1467446492
Provider Name (Legal Business Name): STEPHEN CHARLES PAULK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W LAKE ST
FRIENDSHIP WI
53934-9699
US

IV. Provider business mailing address

402 W LAKE ST
FRIENDSHIP WI
53934-9699
US

V. Phone/Fax

Practice location:
  • Phone: 608-339-3331
  • Fax: 608-339-9385
Mailing address:
  • Phone: 608-339-3331
  • Fax: 608-339-9385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number36262
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36262-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: