Provider Demographics
NPI:1710927835
Name:BLACK, BRENT D (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:D
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE
Mailing Address - Street 2:FL 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 1:2525 HARBOR BLVD
Practice Address - Street 2:104
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5317
Practice Address - Country:US
Practice Address - Phone:941-629-5757
Practice Address - Fax:941-629-7404
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME66098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25336Medicare ID - Type Unspecified
FLF81736Medicare UPIN