Basic Information
| Provider Information | |||||||||
| NPI: | 1861479602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCHETT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3066 E COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782201013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102337074 | ||||||||
| FaxNumber: | 2102775199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 BARCLAY | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782077161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104342368 | ||||||||
| FaxNumber: | 2104340402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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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 | 207Q00000X | F1392 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 040173901 | 05 | TX | MEDICAID |