Healthcare Provider Details

I. General information

NPI: 1962566166
Provider Name (Legal Business Name): BLANCA IVELISSE OSORIO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BLANCA I OSORIO CANDELARIA MD

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 01/02/2021
Certification Date: 01/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 JEFFERSON ST
NATCHITOCHES LA
71457-4350
US

IV. Provider business mailing address

105 JEFFERSON ST
NATCHITOCHES LA
71457-4350
US

V. Phone/Fax

Practice location:
  • Phone: 318-357-2071
  • Fax: 318-521-8031
Mailing address:
  • Phone: 318-357-2071
  • Fax: 318-521-8031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9490A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD 206513
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberTL2329
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number13847
License Number StateHI
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD 206513
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: