Provider Demographics
NPI:1750372405
Name:PAULK, DOUGLAS GORDON (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GORDON
Last Name:PAULK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17375 HALL RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4060
Mailing Address - Country:US
Mailing Address - Phone:586-228-0550
Mailing Address - Fax:586-228-8125
Practice Address - Street 1:17375 HALL RD
Practice Address - Street 2:
Practice Address - City:MACOMB TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48044-4060
Practice Address - Country:US
Practice Address - Phone:586-228-0550
Practice Address - Fax:586-228-8125
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007995208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1886068Medicaid
MIE33210Medicare UPIN
MI1886068Medicaid