Provider Demographics
NPI:1669580098
Name:BLACK, DAVID JOHN (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 E MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4329
Mailing Address - Country:US
Mailing Address - Phone:866-420-2244
Mailing Address - Fax:
Practice Address - Street 1:2211 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4329
Practice Address - Country:US
Practice Address - Phone:360-735-5225
Practice Address - Fax:360-619-4208
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035879208000000X
ORMD20968208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics