Provider Demographics
NPI:1679837066
Name:LEBLANC, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
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 1:1513 LAKELAND DR STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4829
Mailing Address - Country:US
Mailing Address - Phone:601-354-4836
Mailing Address - Fax:601-354-2619
Practice Address - Street 1:3704 HIGHWAY 39 N
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1309
Practice Address - Country:US
Practice Address - Phone:601-693-0216
Practice Address - Fax:601-693-6313
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23514207R00000X, 207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09975030Medicaid
MS09975030Medicaid