Provider Demographics
NPI:1194392910
Name:BLACK, DEMONTERRYO L SR (DO)
Entity Type:Individual
Prefix:MR
First Name:DEMONTERRYO
Middle Name:L
Last Name:BLACK
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:MS
Other - First Name:SHELBY
Other - Middle Name:J
Other - Last Name:BREMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1173 OKEEFFE AVE
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-4236
Mailing Address - Country:US
Mailing Address - Phone:608-906-4343
Mailing Address - Fax:
Practice Address - Street 1:6652 N TOWNE RD APT 121
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:WI
Practice Address - Zip Code:53598-9130
Practice Address - Country:US
Practice Address - Phone:608-906-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide