Provider Demographics
NPI:1871612515
Name:HAIDAK, PAUL M (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:HAIDAK
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 1:105 LEDFORD MILL RD STE B
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-8262
Mailing Address - Country:US
Mailing Address - Phone:931-841-3311
Mailing Address - Fax:931-841-3314
Practice Address - Street 1:105 LEDFORD MILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8261
Practice Address - Country:US
Practice Address - Phone:931-841-3311
Practice Address - Fax:931-841-3314
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44645208200000X, 2082S0105X, 2083A0300X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM11540Medicare ID - Type Unspecified
MAA68240Medicare UPIN