Basic Information
Provider Information | |||||||||
NPI: | 1932112042 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUNN | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | DUSTON | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1301 N RACE ST | ||||||||
Address2: | 1704 WEST STOCKTON STREET | ||||||||
City: | GLASGOW | ||||||||
State: | KY | ||||||||
PostalCode: | 421413454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2706514444 | ||||||||
FaxNumber: | 2706514892 | ||||||||
Practice Location | |||||||||
Address1: | 1704 W STOCKTON ST | ||||||||
Address2: |   | ||||||||
City: | EDMONTON | ||||||||
State: | KY | ||||||||
PostalCode: | 421298137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704324800 | ||||||||
FaxNumber: | 2704324804 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2006 | ||||||||
LastUpdateDate: | 04/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35818 | KY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000000259528 | 01 | KY | BLUE CROSS | OTHER | 64029440 | 05 | KY |   | MEDICAID | 20M1 | 01 | KY | ANTHEN | OTHER |