MEDICARE: CHARLES BALETTE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	12664R	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851358816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES BALETTE M.D.

Provider Business Mailing Address
First Line	:	1417 STILLWATER DR
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-7452
Country	:	US
Telephone Number	:	985-875-9166
Fax Number	:	985-875-9170

Provider Business Practice Location Address
First Line	:	1119 S TYLER ST
Second Line	:
City	:	COVINGTON
State	:	LA
Zip	:	70433
Country	:	US
Telephone Number	:	985-875-9166
Fax Number	:	985-875-9170

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	06/28/2018

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