Provider Demographics
NPI:1821079559
Name:TATUM, PAUL E III (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:TATUM
Suffix:III
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 SPICEWOOD SPRINGS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8645
Mailing Address - Country:US
Mailing Address - Phone:512-397-3360
Mailing Address - Fax:512-343-7107
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022022258207QH0002X
TXR9296207QH0002X, 207QH0002X
IL036160360207QH0002X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ807026Medicaid
AZ76752Medicare ID - Type Unspecified
MOP00676631Medicare PIN
MO152360035Medicare PIN
AZ807026Medicaid
AZ76753Medicare ID - Type Unspecified