Provider Demographics
NPI:1366753584
Name:BLACK, KARIN K (DO)
Entity type:Individual
Prefix:
First Name:KARIN
Middle Name:K
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KARIN
Other - Middle Name:A
Other - Last Name:KROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1400 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2440
Mailing Address - Country:US
Mailing Address - Phone:419-784-1414
Mailing Address - Fax:
Practice Address - Street 1:1400 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2440
Practice Address - Country:US
Practice Address - Phone:419-784-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34011499207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109257Medicaid
OHH089560Medicare PIN