Provider Demographics
NPI:1841414455
Name:BLANCO, THERESA (DO)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8140 SW 136TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-6752
Mailing Address - Country:US
Mailing Address - Phone:305-746-6782
Mailing Address - Fax:305-238-5235
Practice Address - Street 1:17601 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-5001
Practice Address - Country:US
Practice Address - Phone:305-770-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2015-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine