Provider Demographics
NPI:1659393494
Name:BLACK, DEBRA TODD (DO)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:TODD
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:13440 PARKER COMMONS BLVD
Practice Address - Street 2:STE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1816
Practice Address - Country:US
Practice Address - Phone:239-432-9383
Practice Address - Fax:239-432-9392
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 5735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80236WMedicare PIN
FLE66948Medicare UPIN