Provider Demographics
NPI:1619083789
Name:BLANCO, J JOAQUIN (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:JOAQUIN
Last Name:BLANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:J
Other - Last Name:BLANCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:951 NW 13TH ST
Mailing Address - Street 2:5D
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486
Mailing Address - Country:US
Mailing Address - Phone:561-392-7266
Mailing Address - Fax:561-392-7155
Practice Address - Street 1:951 NW 13TH ST
Practice Address - Street 2:5D
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486
Practice Address - Country:US
Practice Address - Phone:561-392-7266
Practice Address - Fax:561-392-7266
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
93314AMedicare ID - Type Unspecified
D60425Medicare UPIN