Provider Demographics
NPI:1881781490
Name:BLACK, DEREK ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ROBERT
Last Name:BLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3060 DAYTON XENIA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6308
Mailing Address - Country:US
Mailing Address - Phone:937-427-2225
Mailing Address - Fax:937-431-1722
Practice Address - Street 1:3060 DAYTON XENIA RD
Practice Address - Street 2:SUITE A
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-6308
Practice Address - Country:US
Practice Address - Phone:937-427-2225
Practice Address - Fax:937-431-1722
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
OH2227111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBL0840122Medicare ID - Type Unspecified
OH0840122Medicare PIN
OHU69539Medicare UPIN