Provider Demographics
NPI:1700836525
Name:PAULK, JACK E (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
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 1:12109 CR 103
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-2967
Mailing Address - Country:US
Mailing Address - Phone:352-391-6494
Mailing Address - Fax:352-391-6498
Practice Address - Street 1:1901 SE 18TH AVE
Practice Address - Street 2:BLDG 300
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-8215
Practice Address - Country:US
Practice Address - Phone:352-351-1313
Practice Address - Fax:352-351-1927
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34723208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067419200Medicaid
FL55112OtherBCBS
FL6219110002Medicare NSC
FL55112ZMedicare PIN
FLD56728Medicare UPIN
FL067419200Medicaid
FL55112YMedicare PIN