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1265460406

NPI Code Detail

MEDICARE: PETER K BLACK MD

MEDICARE: PETER K BLACK MD

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	207R00000X	Internal Medicine Physician	MD61439872	WA
2	2083P0011X	Undersea and Hyperbaric Medicine (Preventive Medicine) Physician	MD24481	OR
3	2083P0011X	Undersea and Hyperbaric Medicine (Preventive Medicine) Physician	MD61439872	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00464800	OTHER	OR	RR MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1265460406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER K BLACK MD

Provider Business Mailing Address
First Line	:	8716 E MILL PLAIN BLVD
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98664-2531
Country	:	US
Telephone Number	:	360-514-4325
Fax Number	:

Provider Business Practice Location Address
First Line	:	8716 E MILL PLAIN BLVD
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98664-2531
Country	:	US
Telephone Number	:	360-514-4325
Fax Number	:	360-514-4336

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	06/26/2025

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Directions to “ PETER K BLACK MD” Practice Location

Language	Start Address	Practice Location

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