Healthcare Provider Details

I. General information

NPI: 1619074531
Provider Name (Legal Business Name): OMAR A BLANCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARCIANO A BLANCO JR.

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-9219
  • Fax:
Mailing address:
  • Phone: 757-668-9219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101222303
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number0101222303
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: