Provider Demographics
NPI:1659392256
Name:BLACK, MICHAEL DARRYL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DARRYL
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 1:927 45TH ST
Mailing Address - Street 2:STE 301
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2450
Mailing Address - Country:US
Mailing Address - Phone:561-227-9240
Mailing Address - Fax:561-842-9570
Practice Address - Street 1:927 45TH ST STE 301
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2450
Practice Address - Country:US
Practice Address - Phone:561-227-9240
Practice Address - Fax:561-842-9570
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110661208G00000X, 208600000X
CAA52781208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003909000Medicaid
CA00A527810Medicaid