1275531469 NPI number — MS. PEDRO ANTONIO BLANDON M.D

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275531469 NPI number — MS. PEDRO ANTONIO BLANDON M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANDON
Provider First Name:
PEDRO
Provider Middle Name:
ANTONIO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1275531469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79995-9520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-760-5317
Provider Business Mailing Address Fax Number:
915-545-6634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4801 ALBERTA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79905-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-545-6618
Provider Business Practice Location Address Fax Number:
915-545-6634
Provider Enumeration Date:
07/12/2005

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: 207R00000X , with the licence number:  L5254 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RN0300X , with the licence number: C1-0006902 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: C1-0006902 . This is a "DELAWARE LICENSE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: L5254 . This is a "TEXAS LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: MD4244 . This is a "CONTROLLED SUBSTANCE #" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1000022966 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: M0145214 . This is a "DPS (CONTROLLED SUBSTANCE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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