Provider Demographics
NPI:1275590473
Name:BLANCO, JESUS (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
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 395
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01473-0395
Mailing Address - Country:US
Mailing Address - Phone:603-673-9411
Mailing Address - Fax:603-673-9899
Practice Address - Street 1:104 WHALON ST
Practice Address - Street 2:SUITE 108
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-7128
Practice Address - Country:US
Practice Address - Phone:978-342-1150
Practice Address - Fax:978-342-4530
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56301207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3040101Medicaid
B75029OtherUPIN
MA3040101Medicaid