Provider Demographics
NPI:1245222595
Name:DEBELLEVUE, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:DEBELLEVUE
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 1:200 W ESPLANADE AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2489
Mailing Address - Country:US
Mailing Address - Phone:504-469-3434
Mailing Address - Fax:504-469-1172
Practice Address - Street 1:200 W ESPLANADE AVE STE 310
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2474
Practice Address - Country:US
Practice Address - Phone:504-469-3434
Practice Address - Fax:504-469-1172
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3109207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1137162Medicaid
LAB62882Medicare UPIN
LA1137162Medicaid