Provider Demographics
NPI:1871004424
Name:BLANCO BENAVIDES, ODELMAN (SA-C)
Entity Type:Individual
Prefix:
First Name:ODELMAN
Middle Name:
Last Name:BLANCO BENAVIDES
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18001 CYPRESS TRACE RD APT 3301
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-1408
Mailing Address - Country:US
Mailing Address - Phone:832-475-7498
Mailing Address - Fax:
Practice Address - Street 1:18001 CYPRESS TRACE RD APT 3301
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-1408
Practice Address - Country:US
Practice Address - Phone:832-475-7498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-22
Last Update Date:2017-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17-546246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant