Healthcare Provider Details

I. General information

NPI: 1407298987
Provider Name (Legal Business Name): DANIEL ALEXANDER BLACK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NATURE WALK PKWY UNIT 105
SAINT AUGUSTINE FL
32092-3066
US

IV. Provider business mailing address

113 NATURE WALK PKWY UNIT 105
SAINT AUGUSTINE FL
32092-3066
US

V. Phone/Fax

Practice location:
  • Phone: 315-382-5910
  • Fax:
Mailing address:
  • Phone: 315-382-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3782
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: