Provider Demographics
NPI:1679700371
Name:LEBLANC, RYAN MONTGOMERY
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MONTGOMERY
Last Name:LEBLANC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1332
Mailing Address - Country:US
Mailing Address - Phone:919-231-6040
Mailing Address - Fax:919-231-6044
Practice Address - Street 1:3905 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1332
Practice Address - Country:US
Practice Address - Phone:919-231-6040
Practice Address - Fax:919-231-6044
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001852152W00000X
NC2159152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCAO5134OtherEYEMED
NC5914851Medicaid
NC0932MOtherBCBS PROV #
NC5914851Medicaid