Healthcare Provider Details

I. General information

NPI: 1053528216
Provider Name (Legal Business Name): JOSHUA BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6839 S CANTON AVE
TULSA OK
74136-3402
US

IV. Provider business mailing address

33 E 26TH ST
TULSA OK
74114-2413
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-0612
  • Fax:
Mailing address:
  • Phone: 804-855-7987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0101241209
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number26838
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: