Provider Demographics
NPI:1760703730
Name:BLACK, ALLYSON (MD)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-773-6470
Mailing Address - Fax:405-773-6463
Practice Address - Street 1:5915 W MEMORIAL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2021
Practice Address - Country:US
Practice Address - Phone:405-773-6470
Practice Address - Fax:405-773-6463
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27886208000000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics