MEDICARE: DR. JEFFREY L. BLACK M.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
1	2085R0202X	Diagnostic Radiology Physician	G14907	CA

General Provider Information

NPI Number	:	1760474035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY L. BLACK M.D.

Provider Business Mailing Address
First Line	:	418 30TH ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94609-3302
Country	:	US
Telephone Number	:	925-274-4950
Fax Number	:	925-274-4975

Provider Business Practice Location Address
First Line	:	418 30TH ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94609-3302
Country	:	US
Telephone Number	:	925-274-4950
Fax Number	:	925-274-4975

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

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	07/20/2007

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