Provider Demographics
NPI:1821032442
Name:BLACK, RONALD V (OD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:V
Last Name:BLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N BRAND BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203
Mailing Address - Country:US
Mailing Address - Phone:818-240-0890
Mailing Address - Fax:818-246-2540
Practice Address - Street 1:330 N BRAND BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2308
Practice Address - Country:US
Practice Address - Phone:818-240-0890
Practice Address - Fax:818-246-2540
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9869T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306035118Medicaid
CA1821032442OtherNPI
CAOPT9869TOtherOPTOMETRY LICENSE
CA6191070001OtherDME MACS PTAN
CAP00741249Medicare PIN
CA1306035118Medicaid
CA1821032442OtherNPI
CABF492AMedicare PIN
CAOPT9869TOtherOPTOMETRY LICENSE
CADP2509Medicare PIN