Provider Demographics
NPI:1043233968
Name:LEBLANC, KIM EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:EDWARD
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 POYDRAS ST
Mailing Address - Street 2:SUITE 1640
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-1221
Mailing Address - Country:US
Mailing Address - Phone:504-412-1835
Mailing Address - Fax:
Practice Address - Street 1:2820 NAPOLEON AVE
Practice Address - Street 2:SUITE 890
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6969
Practice Address - Country:US
Practice Address - Phone:504-412-1366
Practice Address - Fax:504-412-1367
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY014590207QS0010X
LA014590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1309532Medicaid
LA4J321F669Medicare PIN
LA4J321Medicare PIN
B64988Medicare UPIN
LA080192987Medicare PIN