Provider Demographics
NPI:1558389197
Name:BLANCO DUARTE, ROBERTO CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:CARLOS
Last Name:BLANCO DUARTE
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 1:420 DELAWARE ST SE
Mailing Address - Street 2:B 515 MAYO MEMORIAL BLDG MMC294
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-624-9903
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:B 515 MAYO MEMORIAL BLDG MMC294
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-624-9903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010007563207L00000X
FLME116037207L00000X
MN59531207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200431580AMedicaid
MO101740075Medicaid
MO101740075Medicaid
IL$$$$$$$$$Medicaid
MO101740075Medicaid