Basic Information
| Provider Information | |||||||||
| NPI: | 1518957471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | WASHINGTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 490 IH 10 N STE 100 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092129988 | ||||||||
| FaxNumber: | 4092128449 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 IH 10 N STE 100 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092129988 | ||||||||
| FaxNumber: | 4092128449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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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 | 208000000X | 0101235945 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | Q3336 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1518957471 | 05 | VA | MEDICAID |