Provider Demographics
NPI:1811382872
Name:BLACK, CARMEN GABRIELLE (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:GABRIELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:GABRIELLE
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34 PARK ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1109
Mailing Address - Country:US
Mailing Address - Phone:203-974-3000
Mailing Address - Fax:
Practice Address - Street 1:34 PARK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1109
Practice Address - Country:US
Practice Address - Phone:203-974-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0000002084P0800X
390200000X
CT637812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1811382872Medicaid