Provider Demographics
NPI:1275793358
Name:BLACK, ANGELA PREVATT (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:PREVATT
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:RENEE
Other - Last Name:PREVATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT,
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4488
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC,
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:904-697-3792
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME115569207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL'009304000Medicaid