Basic Information
| Provider Information | |||||||||
| NPI: | 1255378535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLASCO | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 725 | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133260725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074331792 | ||||||||
| FaxNumber: | 6074336608 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ONEONTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138202531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074331792 | ||||||||
| FaxNumber: | 6074336519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 06/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 217480 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02283365 | 05 | NY | MEDICAID |