Provider Demographics
NPI:1396831913
Name:BLOCK, KELLY DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DAWN
Last Name:BLOCK
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 1:4855 SW WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3460
Mailing Address - Country:US
Mailing Address - Phone:503-350-2408
Mailing Address - Fax:503-350-2438
Practice Address - Street 1:4855 SW WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3460
Practice Address - Country:US
Practice Address - Phone:503-350-2408
Practice Address - Fax:503-350-2438
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20692174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist