Individual
DESTIN R. BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
2600 KINGS HWY, SUITE 420, SHREVEPORT, LA 71103-3950
(318) 212-8727
(318) 212-8771
Mailing address
2600 KINGS HWY, SUITE 420, SHREVEPORT, LA 71103-3950
(318) 212-8727
(318) 212-8771
Taxonomy
Speciality
Code
Description
License number
State
207VX0201X
Gynecologic Oncology Physician
Primary
024725
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1577936
—
LA
01
—
4K574F600
MEDICARE - PTAN
LA
Enumeration date
04/17/2007
Last updated
06/18/2021
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