Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 1201 | SC |
NPI | 1003828534 |
---|---|
Provider Name | Robert J Black |
First Address | Charlotte, NC 28275-1461 |
Second Address | Charleston, SC 29425-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D12010 | (05) | SC |
T47136 | (02) | SC |