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NPI Code Detail

MEDICARE: DR. D. RUDOLPH BLACK O.D.

MEDICARE: DR. D. RUDOLPH BLACK O.D.
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
1152W00000XOptometrist2311TTX
2152W00000XOptometrist2311TGTX
3152W00000XOptometrist2311TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1508869215
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. D. RUDOLPH BLACK O.D.
Provider Business Mailing Address
First Line : 4401 MARTIN LUTHER KINGS BLVD
Second Line :
City : HOUSTON
State : TX
Zip : 77204-2020
Country : US
Telephone Number : 713-743-2020
Fax Number : 713-743-0963
Provider Business Practice Location Address
First Line : 4401 MARTIN LUTHER KINGS BLVD
Second Line :
City : HOUSTON
State : TX
Zip : 77204-2020
Country : US
Telephone Number : 713-743-2020
Fax Number : 713-743-0963
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/27/2005
Last Update Date : 05/11/2022

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