Provider Demographics
NPI:1568625200
Name:BLANCO, CARLOS JAVIER (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:JAVIER
Last Name:BLANCO
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 1:2501 N ORANGE AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4642
Mailing Address - Country:US
Mailing Address - Phone:407-303-2001
Mailing Address - Fax:
Practice Address - Street 1:2501 N ORANGE AVE STE 310
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4642
Practice Address - Country:US
Practice Address - Phone:407-303-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111671208000000X, 2080P0202X
ARE-66852080P0202X
OH57 0142612080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004344300Medicaid
FLME111671OtherMEDICAL LICENSE
FLFT8652Medicare PIN