Provider Demographics
NPI:1518055490
Name:BLANK, NEAL S (DO)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:S
Last Name:BLANK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12370 HESPERIA RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7719
Mailing Address - Country:US
Mailing Address - Phone:760-245-4747
Mailing Address - Fax:
Practice Address - Street 1:12408 HESPERIA RD
Practice Address - Street 2:SUITE 2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7718
Practice Address - Country:US
Practice Address - Phone:760-553-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 5775207Q00000X
CA20A 12218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine