Provider Demographics
NPI:1548220718
Name:BLACK, DORRIS BETHANY (MD)
Entity Type:Individual
Prefix:DR
First Name:DORRIS
Middle Name:BETHANY
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 SW HK DODGEN LOOP
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3498
Mailing Address - Country:US
Mailing Address - Phone:254-298-2400
Mailing Address - Fax:254-778-7197
Practice Address - Street 1:1905 SW HK DODGEN LOOP
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-3498
Practice Address - Country:US
Practice Address - Phone:254-298-2400
Practice Address - Fax:254-778-7197
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3548208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
8AA947OtherBLUE SHIELD
TXE72602Medicare UPIN