Provider Demographics
NPI:1659588382
Name:BLACK, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 RICHLAND MEDICAL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6834
Mailing Address - Country:US
Mailing Address - Phone:803-765-9233
Mailing Address - Fax:803-779-0344
Practice Address - Street 1:1 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6834
Practice Address - Country:US
Practice Address - Phone:803-765-9233
Practice Address - Fax:803-779-0344
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCTL34783207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology