Provider Demographics
NPI:1508957325
Name:BLACK, LANCE MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:MICHAEL
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 1:997 JOHN WAYNE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-4282
Mailing Address - Country:US
Mailing Address - Phone:850-226-6439
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD
Practice Address - Street 2:SUITE 114
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:850-883-9624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program