Provider Demographics
NPI:1255372363
Name:BLACK, DOUGLAS KEITH (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:KEITH
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 1:1872 CHIMNEY CREEK PL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-1820
Mailing Address - Country:US
Mailing Address - Phone:941-342-1363
Mailing Address - Fax:
Practice Address - Street 1:5350 GULF OF MEXICO DR
Practice Address - Street 2:SUITE #202
Practice Address - City:LONGBOAT KEY
Practice Address - State:FL
Practice Address - Zip Code:34228-2069
Practice Address - Country:US
Practice Address - Phone:941-387-8772
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC-3563152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5496YMedicare ID - Type Unspecified
FLU57828Medicare UPIN