Provider Demographics
NPI:1821002825
Name:BILASANO, VIVIAN BLANQUISCO (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:BLANQUISCO
Last Name:BILASANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 SW 172ND AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5593
Mailing Address - Country:US
Mailing Address - Phone:954-320-7999
Mailing Address - Fax:954-320-7601
Practice Address - Street 1:1951 SW 172ND AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-5593
Practice Address - Country:US
Practice Address - Phone:954-320-7999
Practice Address - Fax:954-320-7601
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 77619207R00000X
FLME77619207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257505100Medicaid
FL49944OtherMEDICARE
ME 77619OtherFL LICENSE
FL257505100Medicaid