Provider Demographics
NPI:1952515595
Name:BLACK, BRENTON L (MD)
Entity type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:L
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:550 PEACHTREE ST NE FL 7
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2247
Mailing Address - Country:US
Mailing Address - Phone:404-686-8181
Mailing Address - Fax:404-686-5905
Practice Address - Street 1:550 PEACHTREE ST NE FL 7
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2247
Practice Address - Country:US
Practice Address - Phone:404-686-8181
Practice Address - Fax:404-686-5905
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2012-10-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA059126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine