Healthcare Provider Details

I. General information

NPI: 1356749006
Provider Name (Legal Business Name): LUIS A. BLANCO M.D. PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8752 SW 8TH ST
MIAMI FL
33174-3201
US

IV. Provider business mailing address

8752 SW 8TH ST
MIAMI FL
33174-3201
US

V. Phone/Fax

Practice location:
  • Phone: 305-554-0044
  • Fax:
Mailing address:
  • Phone: 305-554-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME49234
License Number StateFL

VIII. Authorized Official

Name: DR. LUIS A BLANCO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 305-554-0044