Provider Demographics
NPI:1174552681
Name:PAULSEN, JOHN KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEVIN
Last Name:PAULSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2017
Mailing Address - Country:US
Mailing Address - Phone:309-691-4005
Mailing Address - Fax:309-691-6144
Practice Address - Street 1:7303 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2017
Practice Address - Country:US
Practice Address - Phone:309-691-4005
Practice Address - Fax:309-691-6144
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050399208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050399-2Medicaid
IL7215166OtherBCBS
ILL34250Medicare PIN
IL7215166OtherBCBS