Provider Demographics
NPI:1952475311
Name:LEO BLAIZE III MD
Entity Type:Organization
Organization Name:LEO BLAIZE III MD
Other - Org Name:LAKE INTERNAL MEDICINE AT HENNESSY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR REGION OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MYRTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:AVANTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-202-8078
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:STE 7000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:STE 7000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-8829
Practice Address - Fax:225-765-8283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015394332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1932943OtherOTHER ID NUMBER
1932943OtherOTHER ID NUMBER-COMMERCIAL NUMBER