Provider Demographics
NPI:1821017468
Name:BLACK, RICHARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4670
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43058-4670
Mailing Address - Country:US
Mailing Address - Phone:740-788-3400
Mailing Address - Fax:740-788-3424
Practice Address - Street 1:1445 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1989
Practice Address - Country:US
Practice Address - Phone:740-788-3400
Practice Address - Fax:740-788-3424
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0673462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBL-0879381Medicare PIN