Provider Demographics
NPI:1497724157
Name:PAULK, CLYDE DODSON (MD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:DODSON
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 1:21 OPPORTUNITY DR
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-9185
Mailing Address - Country:US
Mailing Address - Phone:870-942-9833
Mailing Address - Fax:870-942-9837
Practice Address - Street 1:21 OPPORTUNITY DR
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150-9185
Practice Address - Country:US
Practice Address - Phone:870-942-9833
Practice Address - Fax:870-942-9837
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC3204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR770023201OtherBREASTCARE
AR01020368OtherUNITED HEALTHCARE
AR4295730OtherAETNA
AR383494OtherHEATLHLINK
AR102505001Medicaid
AR14003000000OtherQUALCHOICE
AR770023201OtherBREASTCARE
AR102505001Medicaid
AR4295730OtherAETNA
AR012083093Medicare PIN