Provider Demographics
NPI:1962566166
Name:OSORIO, BLANCA IVELISSE (MD)
Entity type:Individual
Prefix:DR
First Name:BLANCA
Middle Name:IVELISSE
Last Name:OSORIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BLANCA
Other - Middle Name:I
Other - Last Name:OSORIO CANDELARIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:105 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-4350
Mailing Address - Country:US
Mailing Address - Phone:318-357-2071
Mailing Address - Fax:318-521-8031
Practice Address - Street 1:105 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-4350
Practice Address - Country:US
Practice Address - Phone:318-357-2071
Practice Address - Fax:318-521-8031
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9490A2084P0800X
LAMD 2065132084P0804X, 2084P0800X
WYTL23292084P0804X
HI13847208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA361581YJR4OtherMEDICARE
LA234404Medicaid