Provider Demographics
NPI:1013186964
Name:BLACK, CHAD ROBINSON (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:ROBINSON
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:
Practice Address - Street 1:3131 LA CANADA ST STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-2579
Practice Address - Country:US
Practice Address - Phone:702-369-5582
Practice Address - Fax:702-369-8470
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 100993207Q00000X
NV20232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20232OtherSTATE LICENSE
NV1013186964Medicaid
FLME100993OtherLICENSE