MEDICARE: LORNA BLANCO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A063801	CA

General Provider Information

NPI Number	:	1093787178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORNA BLANCO M.D.

Provider Business Mailing Address
First Line	:	133 N ALTADENA DR
Second Line	:	2ND FLOOR
City	:	PASADENA
State	:	CA
Zip	:	91107-7325
Country	:	US
Telephone Number	:	626-397-8335
Fax Number	:	626-397-8337

Provider Business Practice Location Address
First Line	:	375 HUNTINGTON DR
Second Line	:	SUITE G
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2357
Country	:	US
Telephone Number	:	626-441-4231
Fax Number	:	626-441-0282

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	01/26/2012

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