Provider Demographics
NPI:1982691077
Name:BLACK, HARRY H (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:H
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:PO BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:201 NORTH CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2724
Practice Address - Country:US
Practice Address - Phone:386-238-3295
Practice Address - Fax:386-328-3273
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048766208600000X
FLME487662086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0048766OtherDCWO
FL08331OtherBCBS
FLP00871769OtherRAILROAD MEDICARE
FLME0048766OtherVHN
FL275548300Medicaid
FL1982691077OtherTRICARE
FL1982691077OtherTRICARE
FL08331WMedicare PIN