Provider Demographics
NPI:1851559504
Name:PRINCESS ANNE PEDIATRICS
Entity Type:Organization
Organization Name:PRINCESS ANNE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-853-3838
Mailing Address - Street 1:5040 E PRINCESS ANNE RD STE A
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1733
Mailing Address - Country:US
Mailing Address - Phone:757-853-3838
Mailing Address - Fax:757-853-0940
Practice Address - Street 1:5040 E PRINCESS ANNE RD STE A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-1733
Practice Address - Country:US
Practice Address - Phone:757-853-3838
Practice Address - Fax:757-853-0940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
22917OtherOPTIMA HEALTH
7543052OtherAETNA U.S. HEALTHCARE
6732305OtherVA PREMIER
VA006732305Medicaid
284466OtherANTHEM BLUE CROSS BLUE SHIELD