Basic Information
| Provider Information | |||||||||
| NPI: | 1619198769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANCO | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 PINE ST APT 2ND | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191064110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179525328 | ||||||||
| FaxNumber: | 2154276782 | ||||||||
| Practice Location | |||||||||
| Address1: | ERIE AVE AT FRON ST - SCPA GASTROENTEROLOGY | ||||||||
| Address2: | NELSON PAVILION STE 2045 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154276778 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 04/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | MT189341 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
No ID Information.