Healthcare Provider Details

I. General information

NPI: 1851392351
Provider Name (Legal Business Name): ANDREW WILLIAM BLACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 N PORTER AVE STE 301
NORMAN OK
73071-6443
US

IV. Provider business mailing address

1125 N PORTER AVE STE 301
NORMAN OK
73071-6443
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-2777
  • Fax: 405-360-2780
Mailing address:
  • Phone: 405-360-2777
  • Fax: 405-360-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME86151
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: