Provider Demographics
NPI:1447384870
Name:BLANCO, TERESA F (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:F
Last Name:BLANCO
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 1:4511 159TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-3147
Mailing Address - Country:US
Mailing Address - Phone:718-939-3022
Mailing Address - Fax:718-460-9505
Practice Address - Street 1:10401 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2327
Practice Address - Country:US
Practice Address - Phone:718-672-1800
Practice Address - Fax:718-424-6876
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00217607Medicaid
NY00217607Medicaid
NY04273Medicare ID - Type Unspecified