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NPI Code Detail

MEDICARE: JEFFREY B BLACK MD

MEDICARE: JEFFREY B BLACK MD
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
1207Q00000XFamily Medicine Physician33020WA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1538137112
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEFFREY B BLACK MD
Provider Business Mailing Address
First Line : PO BOX 5127
Second Line :
City : EVERETT
State : WA
Zip : 98206-5127
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 7205 265TH ST NW
Second Line :
City : STANWOOD
State : WA
Zip : 98292-6221
Country : US
Telephone Number : 360-629-1505
Fax Number : 360-629-1513
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/09/2006
Last Update Date : 12/09/2016

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