Healthcare Provider Details

I. General information

NPI: 1841315504
Provider Name (Legal Business Name): JUDITH C BLAISE MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N ACADIA RD SUITE 202
THIBODAUX LA
70301-4847
US

IV. Provider business mailing address

PO BOX 5237
THIBODAUX LA
70302-5237
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-6444
  • Fax: 985-449-0700
Mailing address:
  • Phone: 985-447-6444
  • Fax: 985-449-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DENISE JONES ADAMS
Title or Position: MANAGER
Credential:
Phone: 985-447-6444