Individual
MR. EDWARD B LACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
540 MEDICAL OAKS AVE, SUITE 102, BRANDON, FL 33511-5995
(813) 651-1991
(813) 651-1401
Mailing address
151 SOUTHHALL LN, SUITE 300, MAITLAND, FL 32751-7176
(407) 875-2080
(407) 650-3544
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
036-043409
IL
207N00000X
Dermatology Physician
ME114654
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0021603804
BCBS
—
Enumeration date
07/12/2005
Last updated
11/15/2016
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