Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DN9155 | FL |
Y | 213EG0000X | General Practice | DN9155 | FL |
NPI | 1003016791 |
---|---|
Provider Name | Dr. Stephen Gary Blank |
First Address | Port Saint Lucie, FL 34986-2451 |
Second Address | Port Saint Lucie, FL 34986-2451 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2007 |
Last Update Date | 20/07/2007 |