Provider Demographics
NPI:1497431811
Name:BLACK, KATRINA (OD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
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 1:4000 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1524
Mailing Address - Country:US
Mailing Address - Phone:502-813-8927
Mailing Address - Fax:
Practice Address - Street 1:3550 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-9315
Practice Address - Country:US
Practice Address - Phone:812-590-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004411A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist