Provider Demographics
NPI:1538162375
Name:BLACK, GREGORY A (DPM)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:BLACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4913 HARROUN RD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2197
Mailing Address - Country:US
Mailing Address - Phone:419-885-4471
Mailing Address - Fax:419-885-0212
Practice Address - Street 1:4913 HARROUN RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2197
Practice Address - Country:US
Practice Address - Phone:419-885-4471
Practice Address - Fax:419-885-0212
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002260213E00000X
OH36.002260213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0614259Medicaid
OHP00457398OtherRAILROAD MEDICARE
OHP00457398OtherRAILROAD MEDICARE
OH6142780001Medicare NSC