=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750339701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALYNIE D BLANCO BURGOS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 03/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ESTANCIAS DEL GOLF CLUB # 101 MIGUEL RIVERA TEXIDOR STREET
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-844-5496
-----------------------------------------------------
Fax | 787-840-0052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | ESTANCIAS DEL GOLF CLUB # 101 MIGUEL RIVERA TEXIDOR STREET
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-844-5496
-----------------------------------------------------
Fax | 787-840-0052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 13881
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------