Provider Demographics
NPI:1699041848
Name:BLACK, KATHERINE WARD (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:WARD
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ANNE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-523-8500
Mailing Address - Fax:952-853-8727
Practice Address - Street 1:3930 NORTHWOODS DR
Practice Address - Street 2:
Practice Address - City:ARDEN HILLS
Practice Address - State:MN
Practice Address - Zip Code:55112-6963
Practice Address - Country:US
Practice Address - Phone:651-523-8500
Practice Address - Fax:651-523-8584
Is Sole Proprietor?:No
Enumeration Date:2012-03-31
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58487207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology