Provider Demographics
NPI:1568578979
Name:PICKHOLTZ, PAUL SANFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:SANFORD
Last Name:PICKHOLTZ
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 1:7557 DANNAHER DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-3558
Mailing Address - Country:US
Mailing Address - Phone:865-859-7330
Mailing Address - Fax:865-859-7339
Practice Address - Street 1:7557 DANNAHER DR
Practice Address - Street 2:SUITE 130
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3558
Practice Address - Country:US
Practice Address - Phone:865-859-7330
Practice Address - Fax:865-859-7339
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD49699207RG0100X
WV23066207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810011422OtherMEDICAID
WVP01203321OtherRR MEDICARE PTAN
WVWV0682AOtherMEDICARE PTAN
WV3810011422OtherMEDICAID
320881Medicare ID - Type Unspecified
NY00553604Medicaid