Provider Demographics
NPI:1578753091
Name:BLACK, TIMOTHY ROGER (DPM)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ROGER
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPM
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Other - Credentials:
Mailing Address - Street 1:1628 ELK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8349
Mailing Address - Country:US
Mailing Address - Phone:208-528-8700
Mailing Address - Fax:208-528-2802
Practice Address - Street 1:3652 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7573
Practice Address - Country:US
Practice Address - Phone:208-528-8700
Practice Address - Fax:208-528-2802
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDP-169213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU92156Medicare UPIN