Healthcare Provider Details

I. General information

NPI: 1316902430
Provider Name (Legal Business Name): ERNESTO JOSE BLANCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 SE 3RD AVE STE 200
FORT LAUDERDALE FL
33316-2521
US

IV. Provider business mailing address

1700 NW 49TH ST STE 125
FORT LAUDERDALE FL
33309-3750
US

V. Phone/Fax

Practice location:
  • Phone: 954-764-0921
  • Fax: 954-467-7432
Mailing address:
  • Phone: 954-764-0921
  • Fax: 954-467-7432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME90706
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberME90706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: