Provider Demographics
NPI:1306062625
Name:BLACK, DESTIN R (MD)
Entity type:Individual
Prefix:
First Name:DESTIN
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2600 KINGS HWY
Mailing Address - Street 2:SUITE 420
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3950
Mailing Address - Country:US
Mailing Address - Phone:318-212-8727
Mailing Address - Fax:318-212-8771
Practice Address - Street 1:2600 KINGS HWY
Practice Address - Street 2:SUITE 420
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3950
Practice Address - Country:US
Practice Address - Phone:318-212-8727
Practice Address - Fax:318-212-8771
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2021-06-18
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Provider Licenses
StateLicense IDTaxonomies
LA024725207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1577936Medicaid
LA4K574F600OtherMEDICARE - PTAN