Provider Demographics
NPI:1588082945
Name:BLASCO, MICHAEL ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:BLASCO
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 1:1 S CLINTON AVE APT 2103
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14604-1744
Mailing Address - Country:US
Mailing Address - Phone:847-609-9580
Mailing Address - Fax:
Practice Address - Street 1:378 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-2200
Practice Address - Country:US
Practice Address - Phone:718-226-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313587-01207Y00000X
IL036.158067207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology