Provider Demographics
NPI:1043270978
Name:BLACK, TIMOTHY E (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
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 29338
Mailing Address - Street 2:DEPT 1014
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038
Mailing Address - Country:US
Mailing Address - Phone:480-844-7100
Mailing Address - Fax:480-512-5486
Practice Address - Street 1:1500 S DOBSON ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:480-844-7100
Practice Address - Fax:480-512-5486
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ17223207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ273673Medicaid
Z65560Medicare ID - Type Unspecified
AZ273673Medicaid