Provider Demographics
NPI:1942343074
Name:BLACK, FREDERICK J (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:J
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2282 NW TROOST ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-6071
Mailing Address - Country:US
Mailing Address - Phone:541-672-0497
Mailing Address - Fax:541-957-2663
Practice Address - Street 1:2282 NW TROOST ST
Practice Address - Street 2:SUITE 103
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6071
Practice Address - Country:US
Practice Address - Phone:541-672-0497
Practice Address - Fax:541-957-2663
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR225581Medicaid
OR225581Medicaid
OR112031Medicare ID - Type UnspecifiedMEDICARE