Provider Demographics
NPI:1427017805
Name:BLACK, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:BLACK
Suffix:
Gender:M
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:POBOX 5005
Mailing Address - Street 2:BAY PINES VAMC 114
Mailing Address - City:BAY PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33744
Mailing Address - Country:US
Mailing Address - Phone:727-398-6661
Mailing Address - Fax:727-398-9575
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:BAY PINES VAMC
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:727-398-9575
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME365612085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D62165Medicare UPIN
FL30354Medicare PIN