Basic Information
| Provider Information | |||||||||
| NPI: | 1023167871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAUL | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | ELAVATH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 WILKINSON TRCE | ||||||||
| Address2: | APT 215 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421032488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707812489 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 380 SUWANNEE TRAIL STREET | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708426553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | TP910 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 40628 | 01 | KY | STATE LICENSE | OTHER | FP0082494 | 01 | KY | DEA | OTHER |