Provider Demographics
NPI:1316903396
Name:BLACK, CLIFFORD P JR (MD)
Entity type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:P
Last Name:BLACK
Suffix:JR
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 1:1901 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-3270
Mailing Address - Country:US
Mailing Address - Phone:256-240-9660
Mailing Address - Fax:256-240-9636
Practice Address - Street 1:1901 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-3270
Practice Address - Country:US
Practice Address - Phone:256-240-9660
Practice Address - Fax:256-240-9636
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00014219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051044834OtherBLUE CROSS BLUE SHIELD
AL000044834Medicaid
AL000044834Medicare ID - Type Unspecified
AL000044834Medicaid