Provider Demographics
NPI:1912529512
Name:BLACK, LIESL A (OD)
Entity type:Individual
Prefix:
First Name:LIESL
Middle Name:A
Last Name:BLACK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1921 FRED W MOORE HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-4702
Mailing Address - Country:US
Mailing Address - Phone:810-326-3937
Mailing Address - Fax:
Practice Address - Street 1:3443 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:CASCO
Practice Address - State:MI
Practice Address - Zip Code:48064-1000
Practice Address - Country:US
Practice Address - Phone:586-727-8000
Practice Address - Fax:586-727-8004
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005440152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619270972OtherST CLAIR EYE
MI1730264995OtherST CLAIR EYE