Provider Demographics
NPI:1578655221
Name:BLACK, JANET K (MD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:K
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 1:31860 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3713
Mailing Address - Country:US
Mailing Address - Phone:727-787-6335
Mailing Address - Fax:727-772-2160
Practice Address - Street 1:31860 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3713
Practice Address - Country:US
Practice Address - Phone:727-787-6335
Practice Address - Fax:727-772-2160
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71243208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251594600Medicaid
FL31479Medicare ID - Type Unspecified
FLF89158Medicare UPIN