Provider Demographics
NPI:1891754917
Name:BLANCO, MARIO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
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 1:2815 GREENBRIAR BLVD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-7157
Mailing Address - Country:US
Mailing Address - Phone:561-204-5455
Mailing Address - Fax:561-204-5455
Practice Address - Street 1:2100 PREVATT ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6130
Practice Address - Country:US
Practice Address - Phone:352-308-8903
Practice Address - Fax:352-460-0785
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL90265207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1265798870OtherGROUP NPI
FL269882000Medicaid
I07858Medicare UPIN