Healthcare Provider Details

I. General information

NPI: 1376162065
Provider Name (Legal Business Name): BRANDON GAGE BLACKLEDGE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 YOUREE DR STE 960
SHREVEPORT LA
71115-2355
US

IV. Provider business mailing address

8001 YOUREE DR STE 960
SHREVEPORT LA
71115-2355
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-2746
  • Fax: 318-212-2759
Mailing address:
  • Phone: 318-212-2746
  • Fax: 318-212-2759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number352569
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: