Basic Information
| Provider Information | |||||||||
| NPI: | 1770978025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANCO | ||||||||
| FirstName: | CONOR | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079222104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082734300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 574 SPRINGFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070901001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086737251 | ||||||||
| FaxNumber: | 9086737265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2015 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207YP0228X | 25MB11178700 | NJ | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
No ID Information.