Healthcare Provider Details

I. General information

NPI: 1679837066
Provider Name (Legal Business Name): STEPHEN LEBLANC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 HIGHWAY 39 N
MERIDIAN MS
39301-1309
US

IV. Provider business mailing address

1513 LAKELAND DR STE 101
JACKSON MS
39216-4829
US

V. Phone/Fax

Practice location:
  • Phone: 601-693-0216
  • Fax: 601-693-6313
Mailing address:
  • Phone: 601-354-4836
  • Fax: 601-354-2619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23514
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number23514
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: