Provider Demographics
NPI:1912007311
Name:BLACK, ELLIOTT BUNYAN III (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:BUNYAN
Last Name:BLACK
Suffix:III
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 1:4228 HOUMA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-3000
Mailing Address - Country:US
Mailing Address - Phone:504-883-8900
Mailing Address - Fax:504-883-8901
Practice Address - Street 1:4228 HOUMA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3000
Practice Address - Country:US
Practice Address - Phone:504-883-8900
Practice Address - Fax:504-883-8901
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011207174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist