Provider Demographics
NPI:1386668267
Name:BLACK, KEITH N (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:N
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 10
Mailing Address - Street 2:
Mailing Address - City:PANHANDLE
Mailing Address - State:TX
Mailing Address - Zip Code:79068-0010
Mailing Address - Country:US
Mailing Address - Phone:806-532-2273
Mailing Address - Fax:806-532-2276
Practice Address - Street 1:421 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PANHANDLE
Practice Address - State:TX
Practice Address - Zip Code:79068
Practice Address - Country:US
Practice Address - Phone:806-532-2273
Practice Address - Fax:806-532-2276
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9543207Q00000X
OK1793207Q00000X
VT0320000253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131469204Medicaid
TXE9543OtherUNICARE
TXE9543OtherWORKER'S COMPENSATION
TX80138267OtherRAILROAD MEDICARE
TX108684100OtherFIRST CARE
TX1186100001OtherCIGNA DMERC
TX1186100001OtherPALMETTO DMERC
TX132180100OtherSOUTHWEST LIFE & HEALTH
TX84V315OtherBCBS
TXE9543OtherWORKER'S COMPENSATION
TX1186100001OtherPALMETTO DMERC
TX84V315Medicare PIN