Provider Demographics
NPI:1780737106
Name:BLACK, JOSEPH L (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:L
Last Name:BLACK
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:FAMILY MEDICINE, MAIL CODE FM
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-6616
Mailing Address - Fax:503-346-6846
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:FAMILY MEDICINE SOUTH WATERFRONT CLINIC
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-6616
Practice Address - Fax:503-346-6846
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2012-10-04
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Provider Licenses
StateLicense IDTaxonomies
ORMD13149207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE68597Medicare UPIN
OR011WCJHTAMedicare ID - Type Unspecified