Provider Demographics
NPI:1194080721
Name:LEBLANC, CONSUELO ANA (MD)
Entity type:Individual
Prefix:DR
First Name:CONSUELO
Middle Name:ANA
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CONSUELO
Other - Middle Name:ANA
Other - Last Name:MAYORAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:477 SOUTHWICK RD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-4795
Mailing Address - Country:US
Mailing Address - Phone:413-562-5256
Mailing Address - Fax:413-568-4757
Practice Address - Street 1:477 SOUTHWICK RD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-4795
Practice Address - Country:US
Practice Address - Phone:413-562-5256
Practice Address - Fax:413-568-4757
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212970208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110006138AMedicaid