Provider Demographics
NPI:1295197861
Name:GREENBLATT, ETHAN L (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:L
Last Name:GREENBLATT
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 1:7373 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4373
Mailing Address - Country:US
Mailing Address - Phone:225-246-9790
Mailing Address - Fax:225-246-9100
Practice Address - Street 1:8585 PICARDY AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3748
Practice Address - Country:US
Practice Address - Phone:225-763-4764
Practice Address - Fax:225-763-4549
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA154636207R00000X
390200000X
LA325987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program