Provider Demographics
NPI:1356347884
Name:BLACK, BRADLEY C (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:C
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:302 W 14TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3751
Mailing Address - Country:US
Mailing Address - Phone:812-284-0660
Mailing Address - Fax:812-284-3822
Practice Address - Street 1:302 W 14TH ST
Practice Address - Street 2:STE 100
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3751
Practice Address - Country:US
Practice Address - Phone:812-284-0660
Practice Address - Fax:812-284-3822
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-05-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01027732A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
351995025OtherHUMANA
4114033OtherFIRST HEALTH
000000042712OtherANTHEM
KY1051940OtherPASSPORT
351995025OtherSAGAMORE
4114033OtherAETNA
245535POtherSIHO
918528OtherBLOCK VISION
IN100116130Medicaid
690178OtherFIRST HEALTH
33654OtherIHN
351995025OtherUNITED HEALTHCARE
351995025OtherCIGNA
KY64755762OtherUNISYS
KY64755762OtherUNISYS
IN244560AMedicare UPIN
4114033OtherAETNA