Provider Demographics
NPI:1225077415
Name:BLACK, KYLE E (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:E
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 1:5616 DENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-9252
Mailing Address - Country:US
Mailing Address - Phone:919-358-0756
Mailing Address - Fax:
Practice Address - Street 1:5616 DENWOOD LN
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-9252
Practice Address - Country:US
Practice Address - Phone:919-358-0756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5481207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD8533Medicaid
AKMD8533Medicaid
AK8EC360Medicare ID - Type Unspecified