Provider Demographics
NPI:1417953597
Name:LANDRY, BLAKE C (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:C
Last Name:LANDRY
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 1:2365 GAUSE BLVD E STE E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4142
Mailing Address - Country:US
Mailing Address - Phone:985-643-1194
Mailing Address - Fax:
Practice Address - Street 1:2365 GAUSE BLVD E STE E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4142
Practice Address - Country:US
Practice Address - Phone:985-643-1194
Practice Address - Fax:985-643-8869
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022661207V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA720847461 0009OtherCIGNA
LA153236130118OtherHUMANA
LA0005507718OtherAETNA
LA1494895Medicaid
LA153236130118OtherHUMANA
LA1494895Medicaid