Provider Demographics
NPI:1891737094
Name:BLACK, CARL M (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:M
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3746
Mailing Address - Country:US
Mailing Address - Phone:801-225-6246
Mailing Address - Fax:801-225-1525
Practice Address - Street 1:1034 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3380
Practice Address - Country:US
Practice Address - Phone:801-373-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4737479-12052085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870284448CB1OtherEMIA
UT47374791204001OtherBLUE CROSS
UT666798OtherDMBA
UT107008883101OtherIHC
UT47374791204001OtherBLUE CROSS
UT870284448CB1OtherEMIA
UT002331011Medicare PIN