Provider Demographics
NPI:1992744981
Name:BLACK, CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1534 ELIZABETH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4516
Mailing Address - Country:US
Mailing Address - Phone:318-681-7350
Mailing Address - Fax:318-681-7351
Practice Address - Street 1:1534 ELIZABETH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4516
Practice Address - Country:US
Practice Address - Phone:318-681-7350
Practice Address - Fax:318-681-7351
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL011576208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1169838Medicaid
LA5O286CJ93Medicare PIN
LA1169838Medicaid