Provider Demographics
NPI:1508998824
Name:ALEX D BLANCO, DPM, LLC
Entity Type:Organization
Organization Name:ALEX D BLANCO, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-941-3769
Mailing Address - Street 1:180 LAFAYETTE AVE
Mailing Address - Street 2:APT. 12A
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4719
Mailing Address - Country:US
Mailing Address - Phone:973-941-3769
Mailing Address - Fax:
Practice Address - Street 1:180 LAFAYETTE AVE
Practice Address - Street 2:APT. 12A
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4719
Practice Address - Country:US
Practice Address - Phone:973-941-3769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00277500213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0018171Medicaid
NJ0018171Medicaid
NJ5362930001Medicare NSC
NJU99569Medicare UPIN