Provider Demographics
NPI:1750339701
Name:BLANCO BURGOS, MALYNIE D (MD)
Entity type:Individual
Prefix:DR
First Name:MALYNIE
Middle Name:D
Last Name:BLANCO BURGOS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:ESTANCIAS DEL GOLF CLUB
Mailing Address - Street 2:# 101 MIGUEL RIVERA TEXIDOR STREET
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730
Mailing Address - Country:US
Mailing Address - Phone:787-844-5496
Mailing Address - Fax:787-840-0052
Practice Address - Street 1:ESTANCIAS DEL GOLF CLUB
Practice Address - Street 2:# 101 MIGUEL RIVERA TEXIDOR STREET
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-844-5496
Practice Address - Fax:787-840-0052
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR13881207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR142273OtherNARCOTIC STATE LISENCE
PR13881OtherMEDICAL LISENCE
PRBB7545695OtherNARCOTI FEDERAL LISENCE
PRBB7545695OtherNARCOTI FEDERAL LISENCE