Healthcare Provider Details

I. General information

NPI: 1417319187
Provider Name (Legal Business Name): PAUL BLACKCLOUD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 07/07/2023
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CELEBRATION DR
ROCHESTER NY
14620-2664
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 278797
ROCHESTER NY
14642-5631
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-7546
  • Fax:
Mailing address:
  • Phone: 585-275-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number309252
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number309252
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: