Provider Demographics
NPI:1124183439
Name:LEBLANC, RONALD DALE (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:DALE
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 ROBERT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2069
Mailing Address - Country:US
Mailing Address - Phone:985-646-2411
Mailing Address - Fax:985-646-2413
Practice Address - Street 1:1120 ROBERT BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458
Practice Address - Country:US
Practice Address - Phone:985-646-2411
Practice Address - Fax:985-646-2413
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09146207RH0003X
LA06459R207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116306Medicaid
LA1367044Medicaid
MSD84357Medicare UPIN
MS830007562Medicare PIN
LA53006Medicare PIN
LA53006C906Medicare PIN
MS00116306Medicaid