Provider Demographics
NPI:1811008865
Name:BLACK, LUCIEN VANDY (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCIEN
Middle Name:VANDY
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 1:1600 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3003
Mailing Address - Country:US
Mailing Address - Phone:352-273-9120
Mailing Address - Fax:352-294-8091
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-9120
Practice Address - Fax:352-294-8091
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2056212080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2314939Medicaid
AL009936558Medicaid
FL015132900Medicaid
AL009936557Medicaid
AL009936558Medicaid
AL009936557Medicaid
FL015132900Medicaid