Provider Demographics
NPI:1164454849
Name:BELLANGER, TRACIE MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:MANUEL
Last Name:BELLANGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:318-966-4000
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:1805 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-2529
Practice Address - Country:US
Practice Address - Phone:318-966-4000
Practice Address - Fax:318-966-7364
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01134207R00000X
LA024891207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1569119Medicaid
LAH99089Medicare UPIN
LA4F642Medicare ID - Type Unspecified