Provider Demographics
NPI:1801077797
Name:PAULSON, JOHN DERICK (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DERICK
Last Name:PAULSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:
Practice Address - Street 1:530 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3084
Practice Address - Country:US
Practice Address - Phone:417-782-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D0679044OtherCLIA
MO597780303OtherRH MEDICAID
MOP00849708OtherRR MEDICARE
MO1801077797Medicaid
MO26-8535OtherRH MEDICARE
MO1235178930Medicaid
MO1447412770Medicaid
MO26D0889777OtherCLIA
MO121690005Medicare PIN
MO26D0679044OtherCLIA
MOP00849708OtherRR MEDICARE