Provider Demographics
NPI:1639108186
Name:BLACK, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
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 1:3600 GASTON AVE
Mailing Address - Street 2:BARNETT TOWER, SUITE 707
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-823-6492
Mailing Address - Fax:214-818-9180
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:WADLEY TOWER, SUITE 261
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-823-6492
Practice Address - Fax:214-818-9180
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1979207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83P753OtherBLUE CROSS BLUE SHIELD
TXP00128419OtherRAILROAD MEDICARE
TX042638901Medicaid
TXG97538Medicare UPIN
TX83P753Medicare ID - Type Unspecified