Provider Demographics
NPI:1861835308
Name:BLACK, TREVOR ELAN (DPM)
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:ELAN
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 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:
Practice Address - Street 1:20 GLENLAKE PKWY
Practice Address - Street 2:KAISER PERMANENTE GLENLAKE MEDICAL CENTER
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3473
Practice Address - Country:US
Practice Address - Phone:818-326-1058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAPOD001289213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program