Provider Demographics
NPI:1629369830
Name:BLANCHARD, MIRAN JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRAN
Middle Name:JOEL
Last Name:BLANCHARD
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 1:820 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4539
Mailing Address - Country:US
Mailing Address - Phone:701-234-6161
Mailing Address - Fax:
Practice Address - Street 1:820 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4539
Practice Address - Country:US
Practice Address - Phone:701-234-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1055422085R0001X
MN543562085R0001X
ND390200000X
ND136472085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN920000474Medicare PIN