Provider Demographics
NPI:1962440107
Name:DEBLAQUIERE, MICHELLE D (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:D
Last Name:DEBLAQUIERE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 TILGHMAN DR STE 700
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5879
Mailing Address - Country:US
Mailing Address - Phone:910-892-4092
Mailing Address - Fax:910-892-0788
Practice Address - Street 1:716 N TENTH ST.
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546
Practice Address - Country:US
Practice Address - Phone:910-814-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01400207Q00000X, 207V00000X
KS0531746174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200593670AMedicaid
NC5920461Medicaid
KSA22000001OtherMEDICARE ID
NC5920461Medicaid