Healthcare Provider Details

I. General information

NPI: 1255372363
Provider Name (Legal Business Name): DOUGLAS KEITH BLACK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 GULF OF MEXICO DR SUITE #202
LONGBOAT KEY FL
34228-2069
US

IV. Provider business mailing address

1872 CHIMNEY CREEK PL
SARASOTA FL
34235-1820
US

V. Phone/Fax

Practice location:
  • Phone: 941-387-8772
  • Fax:
Mailing address:
  • Phone: 941-342-1363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC-3563
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: