Basic Information
| Provider Information | |||||||||
| NPI: | 1902008170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLASINI | ||||||||
| FirstName: | WILFREDO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | ATTN: CREDENTIAL DEPT | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | 2392783350 | ||||||||
| Practice Location | |||||||||
| Address1: | 12751 WESTLINKS DR | ||||||||
| Address2: | UNIT 3 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339138615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395619622 | ||||||||
| FaxNumber: | 2397685297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME102349 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZH0000X | 18357 | PR | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZH0000X | ME102349 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | 18357 | PR | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 208D00000X | 18357 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ME102349 | FL | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 003543100 | 05 | FL | MEDICAID |