Provider Demographics
NPI:1902191620
Name:BLACK, DAVID (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:7333 W THOMAS RD STE 18
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-5547
Mailing Address - Country:US
Mailing Address - Phone:623-247-0777
Mailing Address - Fax:623-849-1283
Practice Address - Street 1:1831 E CAMELBACK RD STE B2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4162
Practice Address - Country:US
Practice Address - Phone:602-234-7904
Practice Address - Fax:602-875-0248
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist