Provider Demographics
NPI:1225036445
Name:RORK, PAUL WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WILLIAM
Last Name:RORK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2201 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7025
Practice Address - Country:US
Practice Address - Phone:530-543-5623
Practice Address - Fax:530-541-5738
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4090207Q00000X
CAG41328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A48533Medicare UPIN
NV1225036445Medicaid
NVV100704Medicare PIN
CA080175885OtherMEDICARE RR
CA1225036445Medicaid