Provider Demographics
NPI:1457300550
Name:OSMUNDSEN, BLAKE CARTER (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:CARTER
Last Name:OSMUNDSEN
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 1:5050 NE HOYT ST
Mailing Address - Street 2:SUITE 615
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2991
Mailing Address - Country:US
Mailing Address - Phone:503-231-0407
Mailing Address - Fax:503-231-0484
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 615
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-231-0407
Practice Address - Fax:503-231-0484
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17368207V00000X, 207VG0400X, 207VF0040X
WAMD00044007207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028386Medicaid
OR028386Medicaid
OOWDBCZCMedicare ID - Type Unspecified