Provider Demographics
NPI:1093011660
Name:P.K.PAUL,M.D. PA
Entity Type:Organization
Organization Name:P.K.PAUL,M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PUDICHERY
Authorized Official - Middle Name:K
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-799-3555
Mailing Address - Street 1:705 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2842
Mailing Address - Country:US
Mailing Address - Phone:352-799-3555
Mailing Address - Fax:352-799-9299
Practice Address - Street 1:705 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-2842
Practice Address - Country:US
Practice Address - Phone:352-799-3555
Practice Address - Fax:352-799-9299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0037402207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065645300Medicaid
D85398Medicare UPIN