Provider Demographics
NPI:1902008170
Name:BLASINI, WILFREDO (MD)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:BLASINI
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 102222
Mailing Address - Street 2:ATTN: CREDENTIAL DEPT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:12751 WESTLINKS DR
Practice Address - Street 2:UNIT 3
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8615
Practice Address - Country:US
Practice Address - Phone:239-561-9622
Practice Address - Fax:239-768-5297
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18357207ZH0000X, 207ZP0102X, 208D00000X
FLME102349207ZH0000X, 207ZP0102X, 208D00000X, 207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003543100Medicaid
FLEY859YMedicare PIN
PRHA830ZMedicare PIN