Provider Demographics
NPI:1407298987
Name:BLACK, DANIEL ALEXANDER (DPM)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ALEXANDER
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 NATURE WALK PKWY
Mailing Address - Street 2:UNIT 105
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3066
Mailing Address - Country:US
Mailing Address - Phone:315-382-5910
Mailing Address - Fax:
Practice Address - Street 1:113 NATURE WALK PKWY
Practice Address - Street 2:UNIT 105
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3066
Practice Address - Country:US
Practice Address - Phone:315-382-5910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3782213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO3782OtherLICENSE
FLPENDINGMedicare PIN