Provider Demographics
NPI:1780918276
Name:BLANCO, ERNESTO IGNACIO (MD)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:IGNACIO
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:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4090 BRIARGATE PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7815
Practice Address - Country:US
Practice Address - Phone:720-848-6617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00578052085P0229X
TXM15202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2073579-06Medicaid
TXP01451755OtherRAILROAD MEDICARE
TX2073579-04Medicaid
TXM1520OtherTEXAS MEDICAL LICENSE
TXP01454587OtherRAILROAD MEDICARE
TX2073579-05Medicaid
TXM1520OtherTEXAS MEDICAL LICENSE
TX2073579-04Medicaid