Provider Demographics
NPI:1669453940
Name:BLACK, TIMOTHY L (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
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:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-4157
Mailing Address - Fax:682-885-1903
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-7080
Practice Address - Fax:682-885-7085
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH14672086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750369203OtherNPI GROUP NUMBER
TX8G3393OtherBCBSTX PIN
TX117647108Medicaid
TX117647106Medicaid
TX117647108Medicaid
TX117647106Medicaid
TX8G7178Medicare PIN