Provider Demographics
NPI:1750377495
Name:TABLANTE-BLANCO, JULIETA G (MD)
Entity type:Individual
Prefix:
First Name:JULIETA
Middle Name:G
Last Name:TABLANTE-BLANCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4915
Mailing Address - Country:US
Mailing Address - Phone:512-439-1600
Mailing Address - Fax:844-751-9263
Practice Address - Street 1:7455 W WASHINGTON AVE STE 301
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4340
Practice Address - Country:US
Practice Address - Phone:702-732-3441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV24437207ZP0102X
MI4301078930207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4485240Medicaid
MI4485231Medicaid
MIG93200Medicare UPIN