Provider Demographics
NPI:1578647269
Name:LUIS M BLANDO MD INC
Entity Type:Organization
Organization Name:LUIS M BLANDO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLANDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-487-3881
Mailing Address - Street 1:430 PARK AVENUE
Mailing Address - Street 2:PO BOX 339
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93044
Mailing Address - Country:US
Mailing Address - Phone:805-487-3881
Mailing Address - Fax:805-487-3963
Practice Address - Street 1:430 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041
Practice Address - Country:US
Practice Address - Phone:805-487-3881
Practice Address - Fax:805-487-3963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C411270Medicaid
A88226Medicare UPIN
CA00C411270Medicaid