Provider Demographics
NPI:1831135698
Name:BLANTON, LEONARD GREGORY (MD)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:GREGORY
Last Name:BLANTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 HOSPITAL DR
Mailing Address - Street 2:SUITE 260
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2399
Mailing Address - Country:US
Mailing Address - Phone:318-212-7840
Mailing Address - Fax:318-212-7845
Practice Address - Street 1:2449 HOSPITAL DR
Practice Address - Street 2:SUITE 260
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2399
Practice Address - Country:US
Practice Address - Phone:318-212-7840
Practice Address - Fax:318-212-7845
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021950207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1538515Medicaid
TX060901802Medicaid
LA1538515Medicaid
LAG01908Medicare UPIN