Provider Demographics
NPI:1114379872
Name:BLACK, JULIA L (DO)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:2725 S 144TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5253
Mailing Address - Country:US
Mailing Address - Phone:402-637-0800
Mailing Address - Fax:402-637-0808
Practice Address - Street 1:2725 S 144TH ST STE 212
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5253
Practice Address - Country:US
Practice Address - Phone:402-637-0800
Practice Address - Fax:402-637-0808
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IADO-05227207Q00000X, 207QS0010X
IAR10715207Q00000X
KS94-10056207QS0010X
NE2258207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine