Provider Demographics
NPI:1851484307
Name:BLACK, LISA BREAUX (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:BREAUX
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:895 VERRET ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4635
Mailing Address - Country:US
Mailing Address - Phone:985-200-3225
Mailing Address - Fax:985-746-1204
Practice Address - Street 1:895 VERRET ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4635
Practice Address - Country:US
Practice Address - Phone:985-200-3225
Practice Address - Fax:985-746-5240
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA22558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1490466Medicaid
LAG46268Medicare UPIN
LA1490466Medicaid