Provider Demographics
NPI:1376589218
Name:BLAYLOCK, PAUL D (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 13994
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-0994
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:1881 NW 185TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97006-6822
Practice Address - Country:US
Practice Address - Phone:503-216-9360
Practice Address - Fax:503-216-9363
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD08602207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00208130OtherRR MEDICARE