Provider Demographics
NPI:1154430825
Name:BLANCO DE JESUS, JOSE ANGEL SR (MD)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ANGEL
Last Name:BLANCO DE JESUS
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2060 COLINA ST
Mailing Address - Street 2:URB VALLE ALTO
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730-4139
Mailing Address - Country:US
Mailing Address - Phone:787-259-2496
Mailing Address - Fax:
Practice Address - Street 1:1255 TITO CASTRO AVE
Practice Address - Street 2:PLAZA LAS MONJITAS SUITE 204
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-844-7336
Practice Address - Fax:787-844-7336
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR10080208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF25922Medicare UPIN
PR82320Medicare ID - Type Unspecified