Provider Demographics
NPI:1487386181
Name:BLACK, JOSHUA (OD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SE 15TH RD APT 4K
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33129-1161
Mailing Address - Country:US
Mailing Address - Phone:757-952-9824
Mailing Address - Fax:
Practice Address - Street 1:241 CORPORATE BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4975
Practice Address - Country:US
Practice Address - Phone:757-742-3902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6120152WV0400X
VA0618003243152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy