Provider Demographics
NPI:1265524391
Name:BLACK, CURTIS JAY (MD)
Entity type:Individual
Prefix:
First Name:CURTIS
Middle Name:JAY
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:ATTN: SHMG/HPE
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-568-1053
Mailing Address - Fax:850-568-1053
Practice Address - Street 1:807 HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:WEWAHITCHKA
Practice Address - State:FL
Practice Address - Zip Code:32465-3237
Practice Address - Country:US
Practice Address - Phone:850-568-1053
Practice Address - Fax:850-568-1053
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2015-10-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME 17786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD52386Medicare UPIN