Provider Demographics
NPI:1558780940
Name:LEBLANC, MAVERICK JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:MAVERICK
Middle Name:JOSEPH
Last Name:LEBLANC
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 1:2929 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8034
Mailing Address - Country:US
Mailing Address - Phone:602-470-5560
Mailing Address - Fax:602-470-5064
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-344-1516
Practice Address - Fax:602-344-1004
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170437882085R0202X
LA3225982085R0202X
AZ665562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid