Healthcare Provider Details

I. General information

NPI: 1235133679
Provider Name (Legal Business Name): DAVID L BLACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 MCCLELLAND BLVD
JOPLIN MO
64804-1640
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-2807
  • Fax: 417-781-3309
Mailing address:
  • Phone: 417-347-5400
  • Fax: 417-347-5709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0421272
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number17973
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberR3P27
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: