Provider Demographics
NPI:1770622896
Name:BLACK, DEBORAH NAOMI (MD)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:NAOMI
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:ATT: CVMC FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-225-5650
Mailing Address - Fax:802-225-5651
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:MOB-A SUITE 1
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-225-5650
Practice Address - Fax:802-225-5651
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT042 00097042084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1845Medicaid
VTVN184503OtherMEDICARE PTAN LINKED TO CVMC
G80308Medicare UPIN
VTVN1845Medicare PIN