Provider Demographics
NPI:1528007671
Name:LEBLANC, CHERRYLL A (MD)
Entity Type:Individual
Prefix:
First Name:CHERRYLL
Middle Name:A
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHERRYLL
Other - Middle Name:A
Other - Last Name:BLYTHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4655 CHADWICK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706
Mailing Address - Country:US
Mailing Address - Phone:409-347-4400
Mailing Address - Fax:
Practice Address - Street 1:1613 HARRISON PKWY
Practice Address - Street 2:#200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2853
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:954-851-1758
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013378207P00000X
TXK6085207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113380304Medicaid
TX164362903Medicaid
TX168991102Medicaid
TX168991104Medicaid
TX168991101Medicaid
TX168991101Medicaid
TX8C7999Medicare PIN
TX8C7298Medicare PIN
TX113380304Medicaid
TX164362903Medicaid
TX8C8097Medicare PIN
TX8C8077Medicare PIN