Provider Demographics
NPI:1487638805
Name:BLANCO, ROBERT R (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
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 1:35318 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1924
Mailing Address - Country:US
Mailing Address - Phone:317-528-4200
Mailing Address - Fax:708-422-7186
Practice Address - Street 1:3800 W 203RD ST STE 201
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1185
Practice Address - Country:US
Practice Address - Phone:708-852-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072218207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL316-03486OtherBCBS
IL01621679OtherBCBS
IL036072218Medicaid
IL036072218 / 02Medicaid
IL036072218 / 02Medicaid
IL01621679OtherBCBS