Provider Demographics
NPI:1528049723
Name:BLACK, CHARLES THOMAS (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:THOMAS
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12200 PARK CENTRAL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2116
Mailing Address - Country:US
Mailing Address - Phone:214-483-9300
Mailing Address - Fax:214-483-9301
Practice Address - Street 1:12200 PARK CENTRAL DR STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2116
Practice Address - Country:US
Practice Address - Phone:214-483-9300
Practice Address - Fax:214-483-9301
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF37612086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4130343OtherAETNA
TX138311911Medicaid
TX389962OtherONE HEALTH PLAN
TX127631OtherSUPERIOR CHIP
80390NOtherBLUE CROSS
TX153410004OtherPACIFICARE
TX3725428015OtherCIGNA
TX138311914OtherCSHCN
TX41814OtherAETNA MEDICAID
TX0134405OtherUNITED HEALTH CARE
TX10009560OtherAMERIGROUP
TX138311913Medicaid
TX138311913Medicaid