Provider Demographics
NPI:1538109343
Name:KOZAK, BLAINE E (MD)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:E
Last Name:KOZAK
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 1:2701 NW VAUGHN ST
Mailing Address - Street 2:STE 425
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5311
Mailing Address - Country:US
Mailing Address - Phone:503-227-2400
Mailing Address - Fax:503-227-0218
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-4032
Practice Address - Fax:503-227-0218
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD122632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044271Medicaid
OR044271Medicaid
E41492Medicare UPIN