Provider Demographics
NPI:1790736643
Name:BLANCO, RUPERTO DIVINO JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RUPERTO
Middle Name:DIVINO
Last Name:BLANCO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5838 METRO WAY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9619
Mailing Address - Country:US
Mailing Address - Phone:616-249-5300
Mailing Address - Fax:616-249-5410
Practice Address - Street 1:5838 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9619
Practice Address - Country:US
Practice Address - Phone:616-249-5300
Practice Address - Fax:616-249-5410
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619765Medicaid
MI4878220Medicaid
MI4619756Medicaid
MI4877705Medicaid
MI0P441950001OtherMEDICARE TYPE 1
MI4619765Medicaid
MII12973Medicare UPIN
MIM69390223Medicare ID - Type Unspecified