Provider Demographics
NPI:1821312281
Name:DAVID F PAUL OD PC
Entity Type:Organization
Organization Name:DAVID F PAUL OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:586-573-4477
Mailing Address - Street 1:12415 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3586
Mailing Address - Country:US
Mailing Address - Phone:586-573-4477
Mailing Address - Fax:586-573-0305
Practice Address - Street 1:12415 E 12 MILE ROAD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3586
Practice Address - Country:US
Practice Address - Phone:586-573-4477
Practice Address - Fax:586-573-0305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002487305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E06566Medicare PIN
MIT78243Medicare UPIN
MI0314930001Medicare NSC