Provider Demographics
NPI:1558424085
Name:BLACK, DOUGLAS N (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:N
Last Name:BLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:2000 N PLANO RD
Practice Address - Street 2:SUITE 111
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4427
Practice Address - Country:US
Practice Address - Phone:972-234-3937
Practice Address - Fax:972-234-3982
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4223T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU11931Medicare UPIN
TX00E72LMedicare ID - Type Unspecified