Provider Demographics
NPI:1477744704
Name:LEBLANC, CARMEN ELISA (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:ELISA
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:ELISA
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1800 HOWELL MILL RD NW
Mailing Address - Street 2:SUITE 450
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2538
Mailing Address - Country:US
Mailing Address - Phone:404-355-4393
Mailing Address - Fax:404-609-7646
Practice Address - Street 1:1800 HOWELL MILL RD NW
Practice Address - Street 2:SUITE 450
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2538
Practice Address - Country:US
Practice Address - Phone:404-355-4393
Practice Address - Fax:404-609-7646
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025983390200000X
GA60308207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA668151120AMedicaid
LA1049531Medicaid
GA668151120AMedicaid