Provider Demographics
NPI:1619065513
Name:BLANCO, ROBERT L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
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:PO BOX 162866
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-2866
Mailing Address - Country:US
Mailing Address - Phone:916-452-5909
Mailing Address - Fax:916-487-6858
Practice Address - Street 1:1341 BURNETT WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-2221
Practice Address - Country:US
Practice Address - Phone:916-452-5909
Practice Address - Fax:916-487-6858
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0411472084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G411470Medicaid
CA00G411470OtherPIN
CA2084P0800XOtherTAXONOMY NUMBER
CAZZZ22535ZMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
CA00G411470Medicaid