Provider Demographics
NPI:1386633410
Name:BLACK, JANET L (DPM)
Entity Type:Individual
Prefix:DR
First Name:JANET
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 LAKE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2364
Mailing Address - Country:US
Mailing Address - Phone:352-385-9156
Mailing Address - Fax:352-385-9159
Practice Address - Street 1:3651 LAKE CENTER DR
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2364
Practice Address - Country:US
Practice Address - Phone:352-385-9156
Practice Address - Fax:352-385-9159
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1752213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL480028889OtherRAILROAD MEDICARE
FL87999OtherBCBS PROVIDER ID
FL480028889OtherRAILROAD MEDICARE
FLT84668Medicare UPIN