Provider Demographics
NPI:1285825836
Name:BLACK, PAUL CLIFFORD (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:CLIFFORD
Last Name:BLACK
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 1:1000 GW LN
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2339
Mailing Address - Country:US
Mailing Address - Phone:573-774-2715
Mailing Address - Fax:573-202-2410
Practice Address - Street 1:1000 GW LN
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2339
Practice Address - Country:US
Practice Address - Phone:573-774-2715
Practice Address - Fax:573-202-2410
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020030965207Q00000X
VA0101244723207Q00000X
TN44017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
621584391013OtherTRICARE
165699202OtherBLACK LUNG