Provider Demographics
NPI:1639273253
Name:BLANKENBAKER, RICHARD STANFILL JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:STANFILL
Last Name:BLANKENBAKER
Suffix:JR
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 1:520 SUPERIOR AVE
Mailing Address - Street 2:STE 325
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3667
Mailing Address - Country:US
Mailing Address - Phone:949-548-6634
Mailing Address - Fax:949-548-1431
Practice Address - Street 1:520 SUPERIOR AVE
Practice Address - Street 2:STE 325
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3667
Practice Address - Country:US
Practice Address - Phone:949-548-6634
Practice Address - Fax:949-548-1431
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2023-1626207RI0011X
CAG76312174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA010884465Medicaid
FL278844600Medicaid
FL78304OtherBLUE CROSS FL
FLCC3284OtherRAILROAD MEDICARE
FLCC3284OtherRAILROAD MEDICARE
FL78304OtherBLUE CROSS FL
FLA21520Medicare UPIN