Healthcare Provider Details

I. General information

NPI: 1265933626
Provider Name (Legal Business Name): BLAKE MATHERNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 S I 10 SERVICE RD W STE 204
METAIRIE LA
70001-6418
US

IV. Provider business mailing address

3636 S I 10 SERVICE RD W STE 204
METAIRIE LA
70001-6418
US

V. Phone/Fax

Practice location:
  • Phone: 504-218-4936
  • Fax: 504-218-8241
Mailing address:
  • Phone: 504-218-4936
  • Fax: 504-218-8241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number349073
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number28777
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: