Provider Demographics
NPI:1518542042
Name:BLANCO, DIEGO A (PT)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:A
Last Name:BLANCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4148 N ARMENIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6422
Mailing Address - Country:US
Mailing Address - Phone:813-458-0061
Mailing Address - Fax:
Practice Address - Street 1:4148 N ARMENIA AVE STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6422
Practice Address - Country:US
Practice Address - Phone:813-458-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36719208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation