MEDICARE: DR. THERESA BLANCO D.O.

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	207Q00000X	Family Medicine Physician	OS9997	FL

General Provider Information

NPI Number	:	1841414455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA BLANCO D.O.

Provider Business Mailing Address
First Line	:	8140 SW 136TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33156-6752
Country	:	US
Telephone Number	:	305-746-6782
Fax Number	:	305-238-5235

Provider Business Practice Location Address
First Line	:	17601 NW 2ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33169-5001
Country	:	US
Telephone Number	:	305-770-4500
Fax Number	:

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

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	02/15/2015

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