Provider Demographics
NPI:1043449481
Name:FAUSETT, BLAKE V (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:V
Last Name:FAUSETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 WILLAKENZIE RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7865
Mailing Address - Country:US
Mailing Address - Phone:541-434-0922
Mailing Address - Fax:
Practice Address - Street 1:2550 WILLAKENZIE RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7865
Practice Address - Country:US
Practice Address - Phone:541-434-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35123349207W00000X
KYTP636207W00000X
IN01073972A207W00000X
ORMD175770207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology