Provider Demographics
NPI:1780657791
Name:BLANCHARD, DAVID E (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:EVERARD
Other - Last Name:BLANCHARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2802 S STAPLES ST STE D
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-3615
Mailing Address - Country:US
Mailing Address - Phone:361-257-1909
Mailing Address - Fax:361-371-8376
Practice Address - Street 1:2802 S STAPLES ST STE D
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-3615
Practice Address - Country:US
Practice Address - Phone:361-257-1909
Practice Address - Fax:361-371-8376
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3743207PE0004X, 208D00000X, 207PE0004X
TXAB0094633207P00000X
ILAB2307569207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1780657791Medicaid
WY123163400Medicaid
WY314473OtherBCWY
WY605960009OtherUSDLAB
WYP00363567Medicare PIN
WYE44494Medicare UPIN
WYW20990Medicare PIN
WY123163400Medicaid