Provider Demographics
NPI:1508838871
Name:BLACK, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0034
Mailing Address - Fax:716-323-0292
Practice Address - Street 1:1001 MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1009
Practice Address - Country:US
Practice Address - Phone:716-323-0034
Practice Address - Fax:716-323-0292
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86636208000000X
NY232292208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1212594OtherIHA
000527733002OtherBC/BS
00026910202OtherUNIVERA
NY02577360Medicaid
070804000017OtherFIDELIS
NY000527733001OtherBLUE CROSS BLUE SHIELD
NY00026910201OtherUNIVERA HEALTHCARE
NY02577360Medicaid