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: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4168 SOUTHPOINT PKWY S STE 201
JACKSONVILLE FL
32216-8002
US

IV. Provider business mailing address

1800 DR MARTIN LUTHER KING JR ST N
ST PETERSBURG FL
33704-4222
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-5437
  • Fax: 904-398-3077
Mailing address:
  • Phone: 727-865-4288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: