Provider Demographics
NPI:1457427585
Name:BLACK, MONICA LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:LEE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4741 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-1793
Mailing Address - Country:US
Mailing Address - Phone:865-687-1940
Mailing Address - Fax:865-687-0157
Practice Address - Street 1:4741 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-1793
Practice Address - Country:US
Practice Address - Phone:865-687-1940
Practice Address - Fax:865-687-0157
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17892208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics