Provider Demographics
NPI:1245205228
Name:BLACK, DAVID MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
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 1:625 9TH AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2465
Mailing Address - Country:US
Mailing Address - Phone:360-501-3400
Mailing Address - Fax:360-423-6862
Practice Address - Street 1:625 9TH AVE
Practice Address - Street 2:STE 210
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2465
Practice Address - Country:US
Practice Address - Phone:360-501-3400
Practice Address - Fax:360-423-6862
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023497207X00000X
WAMD00024397207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1014117Medicaid
OR178434Medicaid
OR178434Medicaid
8855004Medicare ID - Type Unspecified