Provider Demographics
NPI:1730519331
Name:WEST TEXAS MATERNAL FETAL MEDICINE CENTER, LLC
Entity type:Organization
Organization Name:WEST TEXAS MATERNAL FETAL MEDICINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-413-9252
Mailing Address - Street 1:PO BOX 4123
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-4123
Mailing Address - Country:US
Mailing Address - Phone:432-582-2277
Mailing Address - Fax:
Practice Address - Street 1:810 N DIXIE BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-2803
Practice Address - Country:US
Practice Address - Phone:432-582-2277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3413207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty