Provider Demographics
NPI:1174519813
Name:PAULK, LAURA R (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:R
Last Name:PAULK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12920 SUGARBLUFF RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34715-6834
Mailing Address - Country:US
Mailing Address - Phone:407-810-3148
Mailing Address - Fax:
Practice Address - Street 1:12920 SUGARBLUFF RD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34715-6834
Practice Address - Country:US
Practice Address - Phone:407-810-3148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME760462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254231500Medicaid
FL254231500Medicaid