Provider Demographics
NPI:1649265232
Name:BLACK, JAMES D (DPM)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ROCHDALE DR S
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-2273
Mailing Address - Country:US
Mailing Address - Phone:248-652-3400
Mailing Address - Fax:248-652-3401
Practice Address - Street 1:101 ROCHDALE DR S
Practice Address - Street 2:SUITE C
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-2273
Practice Address - Country:US
Practice Address - Phone:248-652-3400
Practice Address - Fax:248-652-3401
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJB001105213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0731430001OtherDME - SUPPLIES, EQUIPMENT
MI1626185Medicaid
382583434OtherFEDERAL ID
MI5635035OtherPTAN
485635035OtherBLUE CROSS BLUE SHIELD MICHIGAN
382583434OtherFEDERAL ID
MI1626185Medicaid