MEDICARE: MR. WILLIAM THOMAS BLACK OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	ID0857	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063591162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM THOMAS BLACK OD

Provider Business Mailing Address
First Line	:	420 E ELM ST
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-4846
Country	:	US
Telephone Number	:	208-459-2020
Fax Number	:	208-459-2034

Provider Business Practice Location Address
First Line	:	420 E ELM ST
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-4846
Country	:	US
Telephone Number	:	208-459-2020
Fax Number	:	208-459-2034

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	08/30/2012

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