Provider Demographics
NPI:1770786667
Name:BLACK, JUDY (MD)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 NW EDENBOWER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-229-3309
Practice Address - Street 1:1937 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2720
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3309
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 170104208000000X
IL036113715202C00000X, 208000000X
ORMD170104208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500680833Medicaid
IL036113715Medicaid