Provider Demographics
NPI:1235342957
Name:BLACK, CHRISTOPHER D (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:D
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2490 OKA ST
Mailing Address - Street 2:
Mailing Address - City:KILAUEA
Mailing Address - State:HI
Mailing Address - Zip Code:96754-5332
Mailing Address - Country:US
Mailing Address - Phone:808-828-1418
Mailing Address - Fax:
Practice Address - Street 1:2490 OKA ST
Practice Address - Street 2:
Practice Address - City:KILAUEA
Practice Address - State:HI
Practice Address - Zip Code:96754-5332
Practice Address - Country:US
Practice Address - Phone:808-828-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 9866207Q00000X
HIDOS1460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1235342957Medicare UPIN