Provider Demographics
NPI:1124037726
Name:BLALOCK, ANTHONY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:PAUL
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1270 ATTAKAPAS DR
Mailing Address - Street 2:STE. 103
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6549
Mailing Address - Country:US
Mailing Address - Phone:337-407-1777
Mailing Address - Fax:337-407-1199
Practice Address - Street 1:1270 ATTAKAPAS DR
Practice Address - Street 2:SUITE 103
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6549
Practice Address - Country:US
Practice Address - Phone:337-407-1777
Practice Address - Fax:337-407-1199
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA024394207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1489131Medicaid
LA1489131Medicaid
LA5H660Medicare ID - Type Unspecified