Provider Demographics
NPI:1932185089
Name:BLACK, EVAN H (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:H
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-577-8900
Mailing Address - Fax:313-577-0700
Practice Address - Street 1:4717 ST. ANTOINE
Practice Address - Street 2:KRESGE EYE INSTITUTE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1423
Practice Address - Country:US
Practice Address - Phone:313-577-8900
Practice Address - Fax:313-577-0700
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2021-09-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301071533207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3462161Medicaid
MI0M78860003Medicare PIN
MI3462161Medicaid
MI0P30630015Medicare PIN
G71940Medicare UPIN