MOLLY DIANNE BLACK MD Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****19

License Status

NOT RENEWED

Business

Title

First Name

MOLLY

Middle

DIANNE

Last Name

BLACK

Business Name

MOLLY DIANNE BLACK MD

Original Issue Date

05/14/2009

Effective Date

05/14/2009

Expiration Date

07/31/2011

City

PEORIA

State

Zip

61614

County

PEORIA

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

11/10/2011