Provider Demographics
NPI:1295814903
Name:BLACK, ADAM C (OD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:C
Last Name:BLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 S WASHINGTON ST
Mailing Address - Street 2:STE 3
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-5370
Mailing Address - Country:US
Mailing Address - Phone:630-369-3937
Mailing Address - Fax:630-369-3933
Practice Address - Street 1:16660 S WINDSOR LN
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-6286
Practice Address - Country:US
Practice Address - Phone:510-847-6959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2536152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist