Provider Demographics
NPI:1336131713
Name:BLACK, ALAN WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:WAYNE
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5800 COLONIAL DR
Mailing Address - Street 2:SUITE 308
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5682
Mailing Address - Country:US
Mailing Address - Phone:954-968-5000
Mailing Address - Fax:954-968-8335
Practice Address - Street 1:5800 COLONIAL DR
Practice Address - Street 2:SUITE 308
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5682
Practice Address - Country:US
Practice Address - Phone:954-968-5000
Practice Address - Fax:954-968-8335
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL0034876207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE11887Medicare UPIN
FL05460Medicare ID - Type Unspecified