Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | ME001469 | FL |
Y | 207Q00000X | Family Doctor | ME44628 | FL |
N | 207QA0505X | Family Doctor - Adult Medicine | ME001469 | FL |
NPI | 1295756682 |
---|---|
Provider Name | David Joseph Black |
First Address | Fort Myers, FL 33901-9342 |
Second Address | Gainesville, FL 32606-5603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2006 |
Last Update Date | 28/10/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01395 | BLUECROSS BLUESHIELD FL (01) | FL |
0431362-00 | (05) | FL |
110016276 | RAILROAD MEDICARE (01) | FL |
D50119 | (02) | FL |