Provider Demographics
NPI:1821000191
Name:BLACK, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
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 1:22930 CRENSHAW BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3048
Mailing Address - Country:US
Mailing Address - Phone:310-530-4200
Mailing Address - Fax:310-530-1562
Practice Address - Street 1:22930 CRENSHAW BLVD STE D
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3048
Practice Address - Country:US
Practice Address - Phone:310-530-4200
Practice Address - Fax:310-530-1562
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67618174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G676181Medicaid
CAF86827Medicare UPIN
CA00G676181Medicaid