Healthcare Provider Details

I. General information

NPI: 1588835185
Provider Name (Legal Business Name): MICHAEL SINCLAIR BLUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2008
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E MAIN ST SUITE 106
NEW IBERIA LA
70560-3725
US

IV. Provider business mailing address

124 E MAIN ST SUITE 106
NEW IBERIA LA
70560-3725
US

V. Phone/Fax

Practice location:
  • Phone: 337-321-6288
  • Fax: 504-897-2436
Mailing address:
  • Phone: 337-321-6288
  • Fax: 504-897-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD.203488
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberMD.203488
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number249091
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number236709
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: