Provider Demographics
NPI:1821546797
Name:BLACK, HARRY
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-2436
Mailing Address - Country:US
Mailing Address - Phone:918-825-1405
Mailing Address - Fax:918-825-1406
Practice Address - Street 1:231 E GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-2436
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:918-825-1406
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist