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General NPI Number Information
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NPI Number | 1548463300
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Entity Type | Individual
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Provider Name | JONATHAN S. BLACK M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/08/2007
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Last Update Date | 08/09/2023
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Provider Practice Location Address
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Address Line | 1300 JEFFERSON PARK AVE
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22903-3363
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Country | US
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Telephone | 434-924-5078
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Fax | 434-924-8118
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Provider Business Mailing Address
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Address Line | PO BOX 9007
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22906-9007
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 0101256477
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 0116019221
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 0101256477
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License Number State | VA
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