Healthcare Provider Details

I. General information

NPI: 1932844313
Provider Name (Legal Business Name): ANDREW BLACK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2022
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S DOBSON RD
MESA AZ
85202-4707
US

IV. Provider business mailing address

1400 S DOBSON RD
MESA AZ
85202-4707
US

V. Phone/Fax

Practice location:
  • Phone: 480-412-3000
  • Fax:
Mailing address:
  • Phone: 480-412-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number012303
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: