Provider Demographics
NPI:1538325428
Name:BLANCA LUNA MD PA
Entity Type:Organization
Organization Name:BLANCA LUNA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:CRISTINA
Authorized Official - Last Name:LUNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-279-0040
Mailing Address - Street 1:636 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3260
Mailing Address - Country:US
Mailing Address - Phone:386-279-0040
Mailing Address - Fax:386-279-0034
Practice Address - Street 1:636 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3260
Practice Address - Country:US
Practice Address - Phone:386-279-0040
Practice Address - Fax:386-264-2171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069660207R00000X
FLME69660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261635100Medicaid
FL28295AMedicare Oscar/Certification
FL261635100Medicaid
FLF13847Medicare UPIN