Basic Information
| Provider Information | |||||||||
| NPI: | 1508954975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | REUBEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 WISTERIA DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702195407 | ||||||||
| FaxNumber: | 7702197102 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 WISTERIA DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702195407 | ||||||||
| FaxNumber: | 7702197102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 03/04/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 37486 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000752661B | 05 | GA | MEDICAID |