Provider Demographics
NPI:1942304423
Name:BLACK, JAMES DURWARD JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DURWARD
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:DURWARD
Other - Last Name:BLACK
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 200006
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-9001
Mailing Address - Country:US
Mailing Address - Phone:770-386-1076
Mailing Address - Fax:770-606-0452
Practice Address - Street 1:300 COURTYARD DR.
Practice Address - Street 2:SUITE B
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8535
Practice Address - Country:US
Practice Address - Phone:770-386-1076
Practice Address - Fax:770-606-0452
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28379208800000X
IL036.164834208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581660430OtherTAX ID
GA000320889BMedicaid
GA0245370001Medicare NSC
GA$$$$$$$$$AMedicare PIN