Provider Demographics
NPI:1275689747
Name:BLALOCK, ROBERT L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
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 1:4494 TWINVIEW LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6057
Mailing Address - Country:US
Mailing Address - Phone:504-239-0301
Mailing Address - Fax:504-471-2764
Practice Address - Street 1:200 W ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2489
Practice Address - Country:US
Practice Address - Phone:504-471-2751
Practice Address - Fax:504-471-2764
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13193R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0012799Medicaid
LA0012799Medicaid