Basic Information
| Provider Information | |||||||||
| NPI: | 1497724157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAULK | ||||||||
| FirstName: | CLYDE | ||||||||
| MiddleName: | DODSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 OPPORTUNITY DR | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721509185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709429833 | ||||||||
| FaxNumber: | 8709429837 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 OPPORTUNITY DR | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721509185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709429833 | ||||||||
| FaxNumber: | 8709429837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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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 | 207Q00000X | C3204 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 770023201 | 01 | AR | BREASTCARE | OTHER | 01020368 | 01 | AR | UNITED HEALTHCARE | OTHER | 4295730 | 01 | AR | AETNA | OTHER | 383494 | 01 | AR | HEATLHLINK | OTHER | 102505001 | 05 | AR | MEDICAID | 14003000000 | 01 | AR | QUALCHOICE | OTHER |