Provider Demographics
NPI:1184720542
Name:BLANK, ANDREW J (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:BLANK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-2250
Mailing Address - Country:US
Mailing Address - Phone:609-387-8787
Mailing Address - Fax:609-386-8640
Practice Address - Street 1:911 SUNSET RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-2250
Practice Address - Country:US
Practice Address - Phone:609-387-8787
Practice Address - Fax:609-386-8640
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB54820208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1965301Medicaid
NJ428425Medicare ID - Type Unspecified
NJE70270Medicare UPIN