Individual
TIMOTHY L BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1500 COOPER ST, FORT WORTH, TX 76104-2710
(682) 885-7080
(682) 885-7085
Mailing address
PO BOX 99371, FORT WORTH, TX 76199-0371
(682) 885-4157
(682) 885-1903
Taxonomy
Speciality
Code
Description
License number
State
2086S0120X
Pediatric Surgery Physician
Primary
H1467
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
117647106
—
TX
05
—
117647108
—
TX
01
—
1750369203
NPI GROUP NUMBER
—
01
—
8G3393
BCBSTX PIN
TX
Enumeration date
11/14/2005
Last updated
11/05/2012
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