Healthcare Provider Details

I. General information

NPI: 1467416990
Provider Name (Legal Business Name): JULIA KIM LEBLANC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 10/06/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 SOUTH ROUTE 31
CRYSTAL LAKE IL
60014-8190
US

IV. Provider business mailing address

875 S ROUTE 31
CRYSTAL LAKE IL
60014-8190
US

V. Phone/Fax

Practice location:
  • Phone: 779-220-5500
  • Fax: 779-220-5571
Mailing address:
  • Phone: 779-220-5500
  • Fax: 779-220-5571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01055473
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036093017
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01055473A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: