Provider Demographics
NPI:1497771109
Name:BLAIS, KENDRICK DAVID (DO)
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:DAVID
Last Name:BLAIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 AIRPORT WAY STE 140A
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4055
Mailing Address - Country:US
Mailing Address - Phone:907-457-9355
Mailing Address - Fax:907-457-9356
Practice Address - Street 1:1867 AIRPORT WAY STE 140A
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4055
Practice Address - Country:US
Practice Address - Phone:907-457-9355
Practice Address - Fax:907-457-9356
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA2242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDO43111Medicaid
AKE84788Medicare UPIN
AK151029Medicare ID - Type Unspecified