Provider Demographics
NPI:1508206285
Name:BLACK, JUSTIN CLINT (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CLINT
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-0308
Mailing Address - Country:US
Mailing Address - Phone:828-322-2644
Mailing Address - Fax:828-327-2235
Practice Address - Street 1:18 13TH AVE NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3748
Practice Address - Country:US
Practice Address - Phone:828-322-2644
Practice Address - Fax:828-327-2235
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL35690208D00000X
NC2018-011122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice