Provider Demographics
NPI:1447240593
Name:BLANCO, ANGEL I (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:I
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 1:6400 FANNIN ST STE 2070
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1541
Mailing Address - Country:US
Mailing Address - Phone:713-486-7747
Mailing Address - Fax:
Practice Address - Street 1:6400 FANNIN ST STE 220
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1553
Practice Address - Country:US
Practice Address - Phone:713-704-2650
Practice Address - Fax:713-704-5710
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM10262085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166102702Medicaid
TX166102704OtherCSHCN (MEDICAID)
TXP00859678OtherMEDICARE RAILROAD
TX1447240593OtherBLUE CROSS BLUE SHIELD
TX166102703Medicaid
TX8L23665Medicare PIN
TX8L24027Medicare PIN
TX166102703Medicaid
TX1447240593OtherBLUE CROSS BLUE SHIELD