Provider Demographics
NPI:1194726604
Name:BLACK, DANIEL T (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
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 667
Mailing Address - Street 2:108 GRIFFITH ST
Mailing Address - City:SALE CREEK
Mailing Address - State:TN
Mailing Address - Zip Code:37373-0667
Mailing Address - Country:US
Mailing Address - Phone:423-332-1813
Mailing Address - Fax:423-332-7732
Practice Address - Street 1:108 GRIFFITH ST
Practice Address - Street 2:
Practice Address - City:SALE CREEK
Practice Address - State:TN
Practice Address - Zip Code:37373-9715
Practice Address - Country:US
Practice Address - Phone:423-332-1813
Practice Address - Fax:423-332-7732
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO1671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3319314Medicare ID - Type Unspecified
H94321Medicare UPIN