Healthcare Provider Details

I. General information

NPI: 1275793358
Provider Name (Legal Business Name): ANGELA PREVATT BLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. ANGELA RENEE PREVATT

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10475 CENTURION PKWY N STE 302
JACKSONVILLE FL
32256-5004
US

IV. Provider business mailing address

10475 CENTURION PKWY N STE 302
JACKSONVILLE FL
32256-5004
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-5437
  • Fax: 904-398-3077
Mailing address:
  • Phone: 43-985-4379
  • Fax: 43-983-0779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberME115569
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: