Provider Demographics
NPI:1366904591
Name:BLACK, KARA (DO)
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W MAGNOLIA AVE STE 201&203
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-8517
Mailing Address - Country:US
Mailing Address - Phone:817-912-9270
Mailing Address - Fax:
Practice Address - Street 1:900 W MAGNOLIA AVE STE 201&203
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8517
Practice Address - Country:US
Practice Address - Phone:817-912-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
TXT4124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program