Provider Demographics
NPI:1225071616
Name:BLACK, DAMON A (MD)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:A
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 369
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0369
Mailing Address - Country:US
Mailing Address - Phone:706-291-2077
Mailing Address - Fax:706-235-4177
Practice Address - Street 1:901 N BROAD ST NE
Practice Address - Street 2:SUITE 220
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-5207
Practice Address - Country:US
Practice Address - Phone:706-291-2077
Practice Address - Fax:706-235-4177
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0564092085B0100X, 2085N0700X, 2085P0229X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA649332244AMedicaid
GA923350OtherBCBS OF GEORGIA
GA649332244AMedicaid
GA923350OtherBCBS OF GEORGIA