Healthcare Provider Details

I. General information

NPI: 1891773966
Provider Name (Legal Business Name): RAY GERVACIO FUENTES BLANCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6569 N CHARLES ST STE 401
BALTIMORE MD
21204-6831
US

IV. Provider business mailing address

PO BOX 418953
BOSTON MA
02241-8953
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-8940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD64365
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberD64365
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: