Provider Demographics
NPI:1356303762
Name:BLACK, CYNTHIA JOY (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:JOY
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6495 E BROAD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1541
Mailing Address - Country:US
Mailing Address - Phone:614-866-8077
Mailing Address - Fax:614-866-9752
Practice Address - Street 1:6495 E BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1541
Practice Address - Country:US
Practice Address - Phone:614-866-8077
Practice Address - Fax:614-866-9752
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058707174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0875905Medicaid
OHF09689Medicare UPIN