Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 1611 | OK |
NPI | 1639293087 |
---|---|
Provider Name | Dr. Eddie J Black |
First Address | Cleveland, OK 74020-2206 |
Second Address | Cleveland, OK 74020-2206 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1611 | TYPE I (01) | OK |