Provider Demographics
NPI:1356667430
Name:BLANK, JACKY BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKY
Middle Name:BRUCE
Last Name:BLANK
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 1:6200 SW 73 STREET
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-7679
Mailing Address - Country:US
Mailing Address - Phone:786-662-8400
Mailing Address - Fax:786-662-5314
Practice Address - Street 1:6200 SW 73 STREET
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-7679
Practice Address - Country:US
Practice Address - Phone:786-662-8400
Practice Address - Fax:786-662-5314
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 101336207RP1001X
PAMD 030949 E207RP1001X
FLME101336207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease