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General NPI Number Information
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NPI Number | 1720082167
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Entity Type | Individual
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Provider Name | SUZANNE D BLACK M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/13/2005
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Last Update Date | 11/19/2014
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Provider Practice Location Address
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Address Line | 2714 OSLER BLVD
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City | BRYAN
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State | TX
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Zip | 77802-2517
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Country | US
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Telephone | 979-776-7788
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Fax | 797-776-0848
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Provider Business Mailing Address
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Address Line | 2714 OSLER BLVD
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City | BRYAN
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State | TX
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Zip | 77802-2517
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Country | US
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Telephone | 979-776-7788
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Fax | 797-776-0848
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | H2250
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License Number State | TX
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