Provider Demographics
NPI:1881677987
Name:BLANCO, ALEX D (DPM)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:D
Last Name:BLANCO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 LAFAYETTE AVE
Mailing Address - Street 2:APT 12A
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4746
Mailing Address - Country:US
Mailing Address - Phone:973-941-3769
Mailing Address - Fax:
Practice Address - Street 1:180 LAFAYETTE AVE
Practice Address - Street 2:APT 12A
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4746
Practice Address - Country:US
Practice Address - Phone:973-941-3769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00277500213ES0103X
NYN0060221213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0018171Medicaid
078363Medicare ID - Type Unspecified
NYPJ9801Medicare ID - Type UnspecifiedMANHATTAN
U99569Medicare UPIN