Basic Information
| Provider Information | |||||||||
| NPI: | 1619105004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JOHN-DAVID | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 GAGE BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422268 | ||||||||
| Practice Location | |||||||||
| Address1: | 845 SWIFT BLVD | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099461654 | ||||||||
| FaxNumber: | 5099435652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD60544517 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1619105004 | 05 | WA | MEDICAID | 102931509 | 05 | PA | MEDICAID |