Provider Demographics
NPI:1619074531
Name:BLANCO, OMAR A (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:A
Last Name:BLANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARCIANO
Other - Middle Name:A
Other - Last Name:BLANCO
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 CHILDRENS LN
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1910
Mailing Address - Country:US
Mailing Address - Phone:757-668-9219
Mailing Address - Fax:
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222303208000000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6732305Medicaid
VA6732305Medicaid