Provider Demographics
NPI:1851589055
Name:BLACK, MICHAEL ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12670 CREEKSIDE LN STE 202
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3370
Mailing Address - Country:US
Mailing Address - Phone:239-482-2663
Mailing Address - Fax:239-482-7585
Practice Address - Street 1:12670 CREEKSIDE LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3370
Practice Address - Country:US
Practice Address - Phone:239-482-2663
Practice Address - Fax:239-482-7585
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPL00000830213ES0103X
FLPO3431213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDJ551YOtherMEDICARE PTAN
FLDJ551ZOtherMEDICARE PTAN