Provider Demographics
NPI:1326012741
Name:BLACK, JAMES B (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:B
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 1:114 S TRYON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2149
Mailing Address - Country:US
Mailing Address - Phone:704-377-5963
Mailing Address - Fax:704-375-4003
Practice Address - Street 1:114 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2149
Practice Address - Country:US
Practice Address - Phone:704-377-5963
Practice Address - Fax:704-375-4003
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909105Medicaid
4285047OtherAETNA
4285047OtherAETNA
T64578Medicare UPIN
NC246000Medicare ID - Type Unspecified