Provider Demographics
NPI:1518957471
Name:BLACK, JORGE WASHINGTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:WASHINGTON
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 1:490 IH 10 N STE 100
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1819
Mailing Address - Country:US
Mailing Address - Phone:409-212-9988
Mailing Address - Fax:409-212-8449
Practice Address - Street 1:490 IH 10 N STE 100
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1819
Practice Address - Country:US
Practice Address - Phone:409-212-9988
Practice Address - Fax:409-212-8449
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235945208000000X
TXQ3336208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1518957471Medicaid