Provider Demographics
NPI:1457301921
Name:BLACK, MELISSA L (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 E VENICE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-3197
Mailing Address - Country:US
Mailing Address - Phone:941-485-4868
Mailing Address - Fax:941-488-7917
Practice Address - Street 1:1435 E VENICE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-3074
Practice Address - Country:US
Practice Address - Phone:941-485-4868
Practice Address - Fax:941-484-4084
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7128254OtherAETNA
FL6484136OtherCIGNA
FL20978OtherBLUE CROSS BLUE SHIELD
FL620639500Medicaid
FLU86010Medicare UPIN
FL7128254OtherAETNA