Provider Demographics
NPI:1093368482
Name:BLACK, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
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 1:2502 W SAINT ISABEL ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6318
Mailing Address - Country:US
Mailing Address - Phone:813-874-5707
Mailing Address - Fax:813-874-5908
Practice Address - Street 1:2502 W SAINT ISABEL ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6318
Practice Address - Country:US
Practice Address - Phone:813-874-5707
Practice Address - Fax:813-874-5908
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN29438390200000X
FL155775207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program