Provider Demographics
NPI:1598719882
Name:BLACK, DANIEL R (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5401
Mailing Address - Fax:740-446-5408
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5401
Practice Address - Fax:740-446-5408
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-4704208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0113223000Medicaid
OH0749373Medicaid
200013580OtherRR MEDICARE
000000006573OtherANTHEM BCBS
001714051OtherMOUNTAIN STATE BCBS
OH310917085122OtherCARESOURCE MEDICAID
OH000000185253OtherUNISON MEDICAID
OH0749373OtherMOLINA MEDICAID
OH0645021Medicare PIN
OH310917085122OtherCARESOURCE MEDICAID