Healthcare Provider Details

I. General information

NPI: 1093261646
Provider Name (Legal Business Name): DANIEL BLANCO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 E SOUTHERN AVE
MESA AZ
85206-2747
US

IV. Provider business mailing address

4606 E 87TH PL
TULSA OK
74137
US

V. Phone/Fax

Practice location:
  • Phone: 602-955-1000
  • Fax:
Mailing address:
  • Phone: 918-346-1752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2878
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2197
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: