Provider Demographics
NPI:1093787178
Name:BLANCO, LORNA (MD)
Entity Type:Individual
Prefix:
First Name:LORNA
Middle Name:
Last Name:BLANCO
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 1:133 N ALTADENA DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-7325
Mailing Address - Country:US
Mailing Address - Phone:626-397-8335
Mailing Address - Fax:626-397-8337
Practice Address - Street 1:375 HUNTINGTON DR
Practice Address - Street 2:SUITE G
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2357
Practice Address - Country:US
Practice Address - Phone:626-441-4231
Practice Address - Fax:626-441-0282
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA063801174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98236Medicare UPIN