Provider Demographics
NPI:1821000787
Name:BLACK, GEOFFREY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:WAYNE
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GEOFFREY
Other - Middle Name:WAYNE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2123 EVERGLADE AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-2818
Mailing Address - Country:US
Mailing Address - Phone:559-434-0551
Mailing Address - Fax:
Practice Address - Street 1:29369 AUBERRY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PRATHER
Practice Address - State:CA
Practice Address - Zip Code:93651-9784
Practice Address - Country:US
Practice Address - Phone:559-855-5390
Practice Address - Fax:559-855-5395
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H65208Medicare UPIN