Provider Demographics
NPI:1336675941
Name:PAULK, PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:PAULK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 WARM SPRINGS ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5323
Mailing Address - Country:US
Mailing Address - Phone:706-507-7530
Mailing Address - Fax:
Practice Address - Street 1:2616 WARM SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5323
Practice Address - Country:US
Practice Address - Phone:706-323-3491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA88030207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program