Healthcare Provider Details

I. General information

NPI: 1972765493
Provider Name (Legal Business Name): KEITH GERARD LEBLANC JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 METAIRIE RD SUITE 101
METAIRIE LA
70005-3974
US

IV. Provider business mailing address

1615 METAIRIE RD SUITE 101
METAIRIE LA
70005-3974
US

V. Phone/Fax

Practice location:
  • Phone: 504-644-4226
  • Fax: 504-208-1135
Mailing address:
  • Phone: 504-644-4226
  • Fax: 504-208-1135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD31526
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD.206061
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: