Healthcare Provider Details

I. General information

NPI: 1265460406
Provider Name (Legal Business Name): PETER K BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8716 E MILL PLAIN BLVD
VANCOUVER WA
98664-2531
US

IV. Provider business mailing address

8716 E MILL PLAIN BLVD
VANCOUVER WA
98664-2531
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-4325
  • Fax: 360-514-4336
Mailing address:
  • Phone: 360-514-4325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61439872
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberMD24481
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberMD61439872
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: