Provider Demographics
NPI:1063464949
Name:BLACK, STEVEN G (OD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:G
Last Name:BLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10218
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47801-0218
Mailing Address - Country:US
Mailing Address - Phone:812-299-3937
Mailing Address - Fax:812-299-8670
Practice Address - Street 1:4424 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47801-0218
Practice Address - Country:US
Practice Address - Phone:812-299-3937
Practice Address - Fax:812-299-8670
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDF9692OtherMEDICARE RAILROAD CARRIER
IN100251270Medicaid
IN251790AMedicare PIN
IN100251270Medicaid
INT69621Medicare UPIN