Provider Demographics
NPI:1619198769
Name:BLANCO, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
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 1:535 PINE ST APT 2ND
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4110
Mailing Address - Country:US
Mailing Address - Phone:917-952-5328
Mailing Address - Fax:215-427-6782
Practice Address - Street 1:ERIE AVE AT FRON ST - SCPA GASTROENTEROLOGY
Practice Address - Street 2:NELSON PAVILION STE 2045
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134
Practice Address - Country:US
Practice Address - Phone:215-427-6778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1893412080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology