Provider Demographics
NPI:1720082167
Name:BLACK, SUZANNE D (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:D
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 1:2714 OSLER BLVD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2517
Mailing Address - Country:US
Mailing Address - Phone:979-776-7788
Mailing Address - Fax:797-776-0848
Practice Address - Street 1:2714 OSLER BLVD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2517
Practice Address - Country:US
Practice Address - Phone:979-776-7788
Practice Address - Fax:797-776-0848
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133493001Medicaid
TX00T34FOtherMEDICARE
TX133493007Medicaid
TX133493007Medicaid