Provider Demographics
NPI:1104833904
Name:BLACK, JERROLD G (MD)
Entity type:Individual
Prefix:
First Name:JERROLD
Middle Name:G
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 1:4167 MERCHANT PLZ
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5088
Mailing Address - Country:US
Mailing Address - Phone:703-878-8800
Mailing Address - Fax:703-878-2133
Practice Address - Street 1:4167 MERCHANT PLZ
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5088
Practice Address - Country:US
Practice Address - Phone:703-878-8800
Practice Address - Fax:703-878-2133
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063821A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104833904Medicaid
VA1104833904Medicaid
IN146470D3Medicare PIN