Provider Demographics
NPI:1710981279
Name:BLACK, BRENT DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DALE
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 1:317 S 450 W UNIT D
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-5838
Mailing Address - Country:US
Mailing Address - Phone:435-830-3772
Mailing Address - Fax:
Practice Address - Street 1:317 S 450 W UNIT D
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-5838
Practice Address - Country:US
Practice Address - Phone:435-830-3772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-11
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170138-12052083X0100X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD07592Medicare ID - Type Unspecified