Provider Demographics
NPI:1275654154
Name:BLANCO, CARLOS
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 23RD ST NW APT 6A
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-3323
Mailing Address - Country:US
Mailing Address - Phone:917-617-3245
Mailing Address - Fax:202-301-1282
Practice Address - Street 1:25 W 81ST ST STE 1B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6023
Practice Address - Country:US
Practice Address - Phone:917-617-3245
Practice Address - Fax:202-301-1282
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012747372084P0800X
MIEMC00020242084P0800X
NJ25MA115227002084P0800X
FLME1530122084P0800X
DCMD200001032084P0800X
MDD00803582084P0800X
NY2090662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY209066Medicaid
NY209066Medicaid