Provider Demographics
NPI:1679510184
Name:PAULK, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:801 POINCIANA AVE
Practice Address - Street 2:
Practice Address - City:MAMOU
Practice Address - State:LA
Practice Address - Zip Code:70554-2243
Practice Address - Country:US
Practice Address - Phone:225-803-6707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA199960207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1057703Medicaid
LA1057703Medicaid
LA4J666CP86Medicare ID - Type Unspecified