Provider Demographics
NPI:1063591162
Name:BLACK, WILLIAM THOMAS (OD)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:THOMAS
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 1:420 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4846
Mailing Address - Country:US
Mailing Address - Phone:208-459-2020
Mailing Address - Fax:208-459-2034
Practice Address - Street 1:420 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4846
Practice Address - Country:US
Practice Address - Phone:208-459-2020
Practice Address - Fax:208-459-2034
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDID0857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002752500Medicaid
1592196Medicare ID - Type Unspecified
U33632Medicare UPIN