Provider Demographics
NPI:1083662639
Name:BLACK, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1622 E TURKEYFOOT LAKE RD
Mailing Address - Street 2:#301
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-5277
Mailing Address - Country:US
Mailing Address - Phone:330-344-8565
Mailing Address - Fax:330-896-7085
Practice Address - Street 1:1622 E TURKEYFOOT LAKE RD
Practice Address - Street 2:#301
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-5277
Practice Address - Country:US
Practice Address - Phone:330-344-8565
Practice Address - Fax:330-896-7085
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35057918207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH0743440Medicaid
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH0743440Medicaid