Provider Demographics
NPI:1710910286
Name:BLANCHE, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:BLANCHE
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 1:1310 W. STEWART DRIVE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3856
Mailing Address - Country:US
Mailing Address - Phone:714-997-2224
Mailing Address - Fax:714-997-1187
Practice Address - Street 1:1310 W. STEWART DRIVE
Practice Address - Street 2:SUITE 503
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3856
Practice Address - Country:US
Practice Address - Phone:714-997-2224
Practice Address - Fax:714-997-1187
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39859174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A398590Medicaid
CAA39859OtherLICENSE
WA39859CMedicare ID - Type Unspecified
CA00A398590Medicaid