Provider Demographics
NPI:1164520326
Name:BLANCO-ECCLESTON, MARTIN M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:M
Last Name:BLANCO-ECCLESTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:500 S ANAHEIM HILLS RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4780
Mailing Address - Country:US
Mailing Address - Phone:714-974-2820
Mailing Address - Fax:714-974-1539
Practice Address - Street 1:500 S ANAHEIM HILLS RD
Practice Address - Street 2:SUITE 230
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-4780
Practice Address - Country:US
Practice Address - Phone:714-974-2820
Practice Address - Fax:714-974-1539
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA42392207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
154-668-8OtherECFMG
CA00A423920Medicaid
CA00A423920Medicaid
CA00A423920Medicaid