Provider Demographics
NPI:1568449916
Name:BLAZES, CHRISTOPHER KYNRINT (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:KYNRINT
Last Name:BLAZES
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 1:2626 SW SHERWOOD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-2285
Mailing Address - Country:US
Mailing Address - Phone:215-313-9651
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073837L207P00000X
CAC140172207P00000X
MI4301115779207P00000X, 2084N0400X, 2084P0800X, 2084P0802X
ORMD2034302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018495650001Medicaid
049662Medicare ID - Type Unspecified
H07678Medicare UPIN