Provider Demographics
NPI:1720036387
Name:BLACK, MICHAEL JASON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JASON
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1818 N MEADE ST
Mailing Address - Street 2:SUITE 240 WEST
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3496
Mailing Address - Country:US
Mailing Address - Phone:920-731-8131
Mailing Address - Fax:920-832-0444
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:SUITE 240 WEST
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3496
Practice Address - Country:US
Practice Address - Phone:920-731-8131
Practice Address - Fax:920-832-0444
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-10-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI46688208600000X
WI46688-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery