Provider Demographics
NPI:1003813601
Name:PAULK, EDDIE LYNN (DO)
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:LYNN
Last Name:PAULK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162 BOX 215
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-391-6405
Mailing Address - Fax:618-288-4088
Practice Address - Street 1:2090 VADALABENE DRIVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-288-5403
Practice Address - Fax:618-288-6857
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-29
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9H10207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242830743Medicaid
E43624Medicare UPIN
MOE43624Medicare UPIN
MO242830743Medicaid
MO990205114Medicare PIN