Provider Demographics
NPI:1144209859
Name:FOSSAS BLANCO, JOSE LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:FOSSAS BLANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:LUIS
Other - Last Name:FOSSAS BLANCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:BAYAMON MEDICAL PLAZA
Mailing Address - Street 2:STE 108
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959
Mailing Address - Country:US
Mailing Address - Phone:787-740-2040
Mailing Address - Fax:787-288-8183
Practice Address - Street 1:BAYAMON MEDICAL PLAZA
Practice Address - Street 2:STE 108
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-740-2040
Practice Address - Fax:787-288-8183
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9255208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D38433Medicare UPIN
0081987Medicare UPIN