Provider Demographics
NPI:1356303762
Name:BLACK, CYNTHIA J (MD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 E MAIN ST STE 3100
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1246
Mailing Address - Country:US
Mailing Address - Phone:614-866-8077
Mailing Address - Fax:614-866-9752
Practice Address - Street 1:8050 E MAIN ST STE 3100
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-1246
Practice Address - Country:US
Practice Address - Phone:614-866-8077
Practice Address - Fax:614-866-9752
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.058707208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0875905Medicaid
OHF09689Medicare UPIN