Provider Demographics
NPI:1083656938
Name:BLANCO, JORGE D (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:D
Last Name:BLANCO
Suffix:
Gender:M
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:PO BOX 4123
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-4123
Mailing Address - Country:US
Mailing Address - Phone:432-582-2277
Mailing Address - Fax:432-333-2802
Practice Address - Street 1:420 E 6TH ST STE 202
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4572
Practice Address - Country:US
Practice Address - Phone:432-582-8757
Practice Address - Fax:432-582-8928
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3413207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112711004Medicaid
TX112711004Medicaid
TXC13525Medicare UPIN