Basic Information
| Provider Information | |||||||||
| NPI: | 1013107168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANCHARD | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8230 SUMMA AVE STE C | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257570552 | ||||||||
| FaxNumber: | 8173327349 | ||||||||
| Practice Location | |||||||||
| Address1: | 6300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707914037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256584000 | ||||||||
| FaxNumber: | 2257639997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 200926 | LA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | N6818 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1090646 | 05 | LA | MEDICAID |