MEDICARE: DR. CLYDE DODSON PAULK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	C3204	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	770023201	OTHER	AR	BREASTCARE
2	01020368	OTHER	AR	UNITED HEALTHCARE
3	4295730	OTHER	AR	AETNA
4	383494	OTHER	AR	HEATLHLINK
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	14003000000	OTHER	AR	QUALCHOICE

General Provider Information

NPI Number	:	1497724157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLYDE DODSON PAULK M.D.

Provider Business Mailing Address
First Line	:	21 OPPORTUNITY DR
Second Line	:
City	:	SHERIDAN
State	:	AR
Zip	:	72150-9185
Country	:	US
Telephone Number	:	870-942-9833
Fax Number	:	870-942-9837

Provider Business Practice Location Address
First Line	:	21 OPPORTUNITY DR
Second Line	:
City	:	SHERIDAN
State	:	AR
Zip	:	72150-9185
Country	:	US
Telephone Number	:	870-942-9833
Fax Number	:	870-942-9837

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	06/30/2009

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Directions to “ DR. CLYDE DODSON PAULK M.D.” Practice Location

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