Provider Demographics
NPI:1760074082
Name:GARCIA BLANCO, GERAMY
Entity Type:Individual
Prefix:
First Name:GERAMY
Middle Name:
Last Name:GARCIA BLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16685 SW 80TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-5783
Mailing Address - Country:US
Mailing Address - Phone:786-818-1197
Mailing Address - Fax:
Practice Address - Street 1:8501 SW 124TH AVE STE 205A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4633
Practice Address - Country:US
Practice Address - Phone:786-803-8851
Practice Address - Fax:786-803-8861
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FL11013407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109636700Medicaid