Provider Demographics
NPI:1497790448
Name:BLANCHARD, DEBORAH A (DO)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:BLANCHARD
Suffix:
Gender:F
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:PO BOX 3730
Mailing Address - Street 2:#DINW103
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3730
Mailing Address - Country:US
Mailing Address - Phone:800-878-6698
Mailing Address - Fax:918-665-4180
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:STE T240
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-7711
Practice Address - Fax:503-227-0218
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO213992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130029Medicaid
104209Medicare ID - Type Unspecified
OR130029Medicaid