Provider Demographics
NPI:1952484214
Name:BLANCO E IGLESIAS, MARTA A (MD)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:A
Last Name:BLANCO E IGLESIAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTA
Other - Middle Name:A
Other - Last Name:BLANCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:535 SAYBROOK RD STE 5
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4743
Mailing Address - Country:US
Mailing Address - Phone:860-344-8606
Mailing Address - Fax:860-344-8963
Practice Address - Street 1:535 SAYBROOK RD STE 5
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4743
Practice Address - Country:US
Practice Address - Phone:860-344-8606
Practice Address - Fax:860-344-8963
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036503207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4064721-136-5031Medicaid
CT1365031Medicaid
CT1365031Medicaid
CT4064721-136-5031Medicaid
CT110007051Medicare PIN