Individual
CARL M BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1034 N 500 W, PROVO, UT 84604-3380
(801) 373-7850
Mailing address
560W 800 N, OREM, UT 84057-3746
(801) 225-6246
(801) 225-1525
Taxonomy
Speciality
Code
Description
License number
State
2085N0904X
Nuclear Radiology Physician
4737479-1205
UT
2085R0202X
Diagnostic Radiology Physician
Primary
4737479-1205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
107008883101
IHC
UT
01
—
47374791204001
BLUE CROSS
UT
01
—
666798
DMBA
UT
01
—
870284448CB1
EMIA
UT
Enumeration date
06/12/2006
Last updated
10/22/2015
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