Provider Demographics
NPI:1508826785
Name:BLACK, ROBERT A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:646 VIRGINIA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6612
Mailing Address - Country:US
Mailing Address - Phone:727-724-0425
Mailing Address - Fax:727-724-0425
Practice Address - Street 1:646 VIRGINIA ST STE 200
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6612
Practice Address - Country:US
Practice Address - Phone:727-724-0425
Practice Address - Fax:727-724-0425
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72600207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252533400Medicaid
FL25004YMedicare ID - Type Unspecified
FL252533400Medicaid