Provider Demographics
NPI:1386623742
Name:BLANCO, JOHN S (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
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 29234
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-9234
Mailing Address - Country:US
Mailing Address - Phone:631-329-6925
Mailing Address - Fax:631-329-6951
Practice Address - Street 1:535 EAST 70TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:646-797-8366
Practice Address - Fax:646-797-8361
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY155915207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02942372Medicaid
NY02942372Medicaid