Healthcare Provider Details

I. General information

NPI: 1891737094
Provider Name (Legal Business Name): CARL M BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604-3380
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-4423
  • Fax: 801-357-7626
Mailing address:
  • Phone: 801-351-4423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4737479-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number4737479-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: