Provider Demographics
NPI:1598753832
Name:BLACK, DOUGLAS J (MD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:J
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 NW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-1375
Mailing Address - Country:US
Mailing Address - Phone:561-338-8484
Mailing Address - Fax:561-338-8492
Practice Address - Street 1:1050 NW 15TH STREET
Practice Address - Street 2:SUITE216A
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486
Practice Address - Country:UM
Practice Address - Phone:561-338-8484
Practice Address - Fax:561-338-8492
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH108942084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G49721Medicare UPIN
T400154038Medicare PIN
RE5685Medicare ID - Type Unspecified
AA35042OtherHAR
NH01Y002610NH01OtherBC