Provider Demographics
NPI:1336231562
Name:BLANCO, ANTONIO E (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:E
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 1:30334 OLD DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3215
Mailing Address - Country:US
Mailing Address - Phone:786-243-0149
Mailing Address - Fax:786-243-2612
Practice Address - Street 1:30334 OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-3215
Practice Address - Country:US
Practice Address - Phone:786-243-0149
Practice Address - Fax:786-243-2612
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001084300Medicaid
FL257737201Medicaid
FLF33588Medicare UPIN
FL257737201Medicaid
FL001084300Medicaid
FL17708OMedicare PIN