Provider Demographics
NPI:1750367066
Name:LEBLANC, JOHN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1428
Mailing Address - Country:US
Mailing Address - Phone:207-834-3155
Mailing Address - Fax:
Practice Address - Street 1:194 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1428
Practice Address - Country:US
Practice Address - Phone:207-834-1329
Practice Address - Fax:207-834-2949
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO3066207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDO3066OtherSTATE LICENSE
ME1750367066Medicaid