Provider Demographics
NPI:1609903053
Name:BLACK, PAUL STEVEN (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:STEVEN
Last Name:BLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 D INTERSTATE 45 SO
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340
Mailing Address - Country:US
Mailing Address - Phone:936-291-2770
Mailing Address - Fax:936-291-7422
Practice Address - Street 1:111 D INTERSTATE 45 SO
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340
Practice Address - Country:US
Practice Address - Phone:936-291-2770
Practice Address - Fax:936-291-7422
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E98BOtherBLUE CROSS
T12224Medicare UPIN
TX00E98BOtherBLUE CROSS