MEDICARE: MR. DAVID BLACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	172500	TX

General Provider Information

NPI Number	:	1053536417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID BLACK

Provider Business Mailing Address
First Line	:	1123 WOODBANK DR
Second Line	:
City	:	SEABROOK
State	:	TX
Zip	:	77586-4014
Country	:	US
Telephone Number	:	281-380-3977
Fax Number	:

Provider Business Practice Location Address
First Line	:	1123 WOODBANK DR
Second Line	:
City	:	SEABROOK
State	:	TX
Zip	:	77586-4014
Country	:	US
Telephone Number	:	281-380-3977
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	07/08/2007

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Directions to “ MR. DAVID BLACK ” Practice Location

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