Healthcare Provider Details

I. General information

NPI: 1245205228
Provider Name (Legal Business Name): DAVID MICHAEL BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 9TH AVE STE 210
LONGVIEW WA
98632-2465
US

IV. Provider business mailing address

625 9TH AVE STE 210
LONGVIEW WA
98632-2465
US

V. Phone/Fax

Practice location:
  • Phone: 360-501-3400
  • Fax: 360-423-6862
Mailing address:
  • Phone: 360-501-3400
  • Fax: 360-423-6862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD00023497
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberMD00024397
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: