Provider Demographics
NPI:1124037726
Name:BLALOCK, ANTHONY PAUL (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:PAUL
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:300 W SAINT MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4638
Mailing Address - Country:US
Mailing Address - Phone:337-233-6593
Mailing Address - Fax:337-235-1032
Practice Address - Street 1:2804 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5906
Practice Address - Country:US
Practice Address - Phone:337-981-5156
Practice Address - Fax:337-981-0673
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA024394207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1489131Medicaid
LA1489131Medicaid
LA5H660Medicare ID - Type Unspecified