1073584710 NPI number — DR. CHRISTOPHER JOHN BLANCO D.P.M.

Table of content: (NPI 1659691020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073584710 NPI number — DR. CHRISTOPHER JOHN BLANCO D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANCO
Provider First Name:
CHRISTOPHER
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073584710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8053 NW 114TH PATH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDLEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33178-2510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-953-4466
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 NW 57TH AVE
Provider Second Line Business Practice Location Address:
320
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33126-2072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-264-2632
Provider Business Practice Location Address Fax Number:
305-266-2274
Provider Enumeration Date:
01/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO 3186 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 313984 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 65926 . This is a "BLUECROSS BLUE SHIELDS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 204445857 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 340554100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7060825 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2700492 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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