Provider Demographics
NPI:1750379350
Name:BLANCO, GUILLERMO (MD)
Entity type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
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 1:1990 NE 163RD ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4854
Mailing Address - Country:US
Mailing Address - Phone:305-948-3333
Mailing Address - Fax:305-948-6632
Practice Address - Street 1:1990 NE 163RD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4854
Practice Address - Country:US
Practice Address - Phone:305-948-3333
Practice Address - Fax:305-948-6632
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL444022084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D63865Medicare UPIN
96476Medicare ID - Type Unspecified