Provider Demographics
NPI:1891773966
Name:BLANCO, RAY GERVACIO FUENTES (MD)
Entity Type:Individual
Prefix:DR
First Name:RAY GERVACIO
Middle Name:FUENTES
Last Name:BLANCO
Suffix:
Gender:M
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:PO BOX 418953
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6569 N CHARLES ST
Practice Address - Street 2:STE 401
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6831
Practice Address - Country:US
Practice Address - Phone:443-849-8940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD64365208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKG72GB/89135601OtherCAREFIRST MARYLAND
MD411454000Medicaid
MDS1430006OtherCAREFIRST REGIONAL
MDS1430006OtherCAREFIRST REGIONAL
I40736Medicare UPIN
MD676LO815Medicare PIN
MDP00346690Medicare PIN