Provider Demographics
NPI:1053351361
Name:BLACK, STUART (MD)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-466-7869
Mailing Address - Fax:208-466-5359
Practice Address - Street 1:223 16TH AVE N
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-4058
Practice Address - Country:US
Practice Address - Phone:208-466-7869
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060962A207Q00000X
IDM-9850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID11000132OtherMEDICARE PTAN
ID11000133OtherMEDICARE PTAN
ID1053351361Medicaid
ID11000131OtherMEDICARE PTAN
IDP00777176OtherMEDICARE RAILROAD PTAN
IDM9850OtherIDAHO LICENSE
IDP00777176OtherMEDICARE RAILROAD PTAN