Healthcare Provider Details

I. General information

NPI: 1326365123
Provider Name (Legal Business Name): BLAKE LEBLANC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 WOLF CIRCLE
LAKE CHARLES LA
70605
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-433-8400
  • Fax:
Mailing address:
  • Phone: 337-312-8258
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD.204906
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: