Healthcare Provider Details

I. General information

NPI: 1982691077
Provider Name (Legal Business Name): HARRY H BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NORTH CLYDE MORRIS BLVD SUITE 100
DAYTONA BEACH FL
32114-2724
US

IV. Provider business mailing address

PO BOX 9671
DAYTONA BEACH FL
32120-9671
US

V. Phone/Fax

Practice location:
  • Phone: 386-238-3295
  • Fax: 386-328-3273
Mailing address:
  • Phone: 386-676-7130
  • Fax: 386-676-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0048766
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME48766
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: