Healthcare Provider Details

I. General information

NPI: 1396948964
Provider Name (Legal Business Name): NANCY BLACE M.D.PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7606
US

IV. Provider business mailing address

PO BOX 570169
WHITESTONE NY
11357-0169
US

V. Phone/Fax

Practice location:
  • Phone: 718-901-8918
  • Fax: 718-313-0194
Mailing address:
  • Phone: 646-361-4610
  • Fax: 718-313-0194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number0244436
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number244436
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: