Provider Demographics
NPI:1962893156
Name:DAVID J. BLACK
Entity type:Organization
Organization Name:DAVID J. BLACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-375-6708
Mailing Address - Street 1:720 SW 2ND AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-1210
Mailing Address - Country:US
Mailing Address - Phone:352-376-7751
Mailing Address - Fax:
Practice Address - Street 1:720 SW 2ND AVE STE 206
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-1210
Practice Address - Country:US
Practice Address - Phone:352-376-7751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMEOO44628207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1295756682Medicare UPIN