Healthcare Provider Details

I. General information

NPI: 1124037726
Provider Name (Legal Business Name): ANTHONY PAUL BLALOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/24/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-5906
US

IV. Provider business mailing address

300 W SAINT MARY BLVD
LAFAYETTE LA
70506-4638
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-5156
  • Fax: 337-981-0673
Mailing address:
  • Phone: 337-233-6593
  • Fax: 337-235-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number024394
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: