Provider Demographics
NPI:1952479750
Name:BLANCAFLOR, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:BLANCAFLOR
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 1:400 SAYBROOK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-347-9167
Mailing Address - Fax:860-347-1630
Practice Address - Street 1:400 SAYBROOK RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-347-9167
Practice Address - Fax:860-347-1630
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030814208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020020467OtherRAILROAD-MEDICARE
CT706822OtherCONNECTICARE
CT001308148Medicaid
CT020020467OtherRAILROAD-MEDICARE
E74314Medicare UPIN