Provider Demographics
NPI:1265439723
Name:BLACK, HERBERT T (OD)
Entity type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:T
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 1:3098 S IVAN WAY
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80227-3838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:720-218-8741
Practice Address - Street 1:1222 PUTNEY RD
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-9000
Practice Address - Country:US
Practice Address - Phone:802-254-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2081152W00000X
VT030.0069859152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU94359Medicare UPIN