Provider Demographics
NPI:1467499954
Name:BLACK, KERTIA LIBRETTO (MD)
Entity Type:Individual
Prefix:
First Name:KERTIA
Middle Name:LIBRETTO
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 1:27725 RAINBOW CIR
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3238
Mailing Address - Country:US
Mailing Address - Phone:248-910-7018
Mailing Address - Fax:248-557-5409
Practice Address - Street 1:27725 RAINBOW CIR
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-3238
Practice Address - Country:US
Practice Address - Phone:248-910-7018
Practice Address - Fax:248-557-5409
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061932208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630014Medicare PIN