Healthcare Provider Details

I. General information

NPI: 1275578130
Provider Name (Legal Business Name): JUDITH CANELLA BLAISE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N ACADIA RD
THIBODAUX LA
70301-4823
US

IV. Provider business mailing address

PO BOX 5237
THIBODAUX LA
70302-5237
US

V. Phone/Fax

Practice location:
  • Phone: 985-493-4706
  • Fax: 985-449-2595
Mailing address:
  • Phone: 985-803-0584
  • Fax: 985-449-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number020707
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberMD.020707
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: