Provider Demographics
NPI:1699721548
Name:BLACK, JANIS G (DO)
Entity type:Individual
Prefix:DR
First Name:JANIS
Middle Name:G
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JANIS
Other - Middle Name:L
Other - Last Name:GERBRACT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3740 CURTIS BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-3962
Mailing Address - Country:US
Mailing Address - Phone:321-633-5500
Mailing Address - Fax:321-633-5566
Practice Address - Street 1:3740 CURTIS BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-3962
Practice Address - Country:US
Practice Address - Phone:321-633-5500
Practice Address - Fax:321-633-5566
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275301400Medicaid
FL52558OtherBLUE CROSS BLUE SHIELD
FL8727208OtherCIGNA
FL7615827OtherAETNA
FL275301400Medicaid
FL52558OtherBLUE CROSS BLUE SHIELD
FL7615827OtherAETNA