Provider Demographics
NPI:1336137876
Name:MAVROMATIS, BLANCHE (MD)
Entity Type:Individual
Prefix:
First Name:BLANCHE
Middle Name:
Last Name:MAVROMATIS
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:PO BOX 631872
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:904 SETON DR
Practice Address - Street 2:SUITE 205
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1849
Practice Address - Country:US
Practice Address - Phone:301-723-5279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC31877207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC000Y70G93Medicare PIN
H17316Medicare UPIN