Provider Demographics
NPI:1710925334
Name:CHAULK, JEFFREY KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KENNETH
Last Name:CHAULK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1665
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49734-5665
Mailing Address - Country:US
Mailing Address - Phone:989-732-6455
Mailing Address - Fax:989-732-1102
Practice Address - Street 1:350 W NORTH ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1525
Practice Address - Country:US
Practice Address - Phone:989-732-6455
Practice Address - Fax:989-732-1102
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301405077207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI180012703OtherRAILROAD MEDICARE
MI1806920011OtherBCBS
MA0585020001OtherADMINASTAR FEDERAL
MI3038315Medicaid
MI0F94502001OtherMEDICARE PLUS BLUE
MI0F94502001Medicare ID - Type Unspecified
MI180012703OtherRAILROAD MEDICARE
MIF94502001Medicare PIN