Healthcare Provider Details

I. General information

NPI: 1962479881
Provider Name (Legal Business Name): JAMES ALLEN BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 E 31ST PL
YUMA AZ
85365-6553
US

IV. Provider business mailing address

5911 N BRONCO ST
LAS VEGAS NV
89130-1355
US

V. Phone/Fax

Practice location:
  • Phone: 928-341-4544
  • Fax: 928-341-4514
Mailing address:
  • Phone: 240-731-8115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number35057615
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number43185
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: