1275793358 NPI number — DR. ANGELA PREVATT BLACK MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275793358 NPI number — DR. ANGELA PREVATT BLACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
ANGELA
Provider Middle Name:
PREVATT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PREVATT
Provider Other First Name:
ANGELA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275793358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 DR MARTIN LUTHER KING JR ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33704-4222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-865-4288
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4168 SOUTHPOINT PKWY S STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-8002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-398-5437
Provider Business Practice Location Address Fax Number:
904-398-3077
Provider Enumeration Date:
06/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YP0228X , with the licence number: ME115569 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: '009304000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009304000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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