Provider Demographics
NPI:1801238100
Name:BLASCO, NICHOLAS JAMES (OD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:BLASCO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W DUNDEE RD
Mailing Address - Street 2:STE 14-15
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3415
Mailing Address - Country:US
Mailing Address - Phone:515-306-7213
Mailing Address - Fax:
Practice Address - Street 1:2566 HUBBELL AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-6102
Practice Address - Country:US
Practice Address - Phone:515-262-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-27
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2370152W00000X
IL046011522152W00000X
IA002583152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist