Provider Demographics
NPI:1184633687
Name:BLANCO, EDISON ROQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDISON
Middle Name:ROQUE
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 1:16 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8011
Mailing Address - Country:US
Mailing Address - Phone:631-969-7875
Mailing Address - Fax:631-969-7883
Practice Address - Street 1:16 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8011
Practice Address - Country:US
Practice Address - Phone:631-969-7875
Practice Address - Fax:631-969-7883
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01634335Medicaid
NY01634335Medicaid
NYF33401Medicare UPIN