Provider Demographics
NPI:1720081169
Name:WHITEHEAD, PAUL S (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:WHITEHEAD
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 1:3200 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1722
Mailing Address - Country:US
Mailing Address - Phone:585-394-4846
Mailing Address - Fax:585-394-1309
Practice Address - Street 1:3200 WEST ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1722
Practice Address - Country:US
Practice Address - Phone:585-394-4846
Practice Address - Fax:585-394-1309
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2007-09-27
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
NY147416174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00902685Medicaid
NYD01760Medicare UPIN
NY00902685Medicaid