Individual
JERROLD G BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4167 MERCHANT PLZ, WOODBRIDGE, VA 22192-5088
(703) 878-8800
(703) 878-2133
Mailing address
4167 MERCHANT PLZ, WOODBRIDGE, VA 22192-5088
(703) 878-8800
(703) 878-2133
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01063821A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1104833904
—
VA
Enumeration date
08/02/2006
Last updated
02/28/2011
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