Provider Demographics
NPI:1851464366
Name:BLACK, STANLEY R (OD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:R
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 1:4 GARDEN CTR
Mailing Address - Street 2:STE 100
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-7026
Mailing Address - Country:US
Mailing Address - Phone:303-469-1941
Mailing Address - Fax:303-469-6634
Practice Address - Street 1:12450 YORK ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80241-2741
Practice Address - Country:US
Practice Address - Phone:303-452-2020
Practice Address - Fax:303-452-0934
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO301007Medicare PIN
COT60748Medicare UPIN