Provider Demographics
NPI:1609078229
Name:DONALD W BLOCKER DO
Entity Type:Organization
Organization Name:DONALD W BLOCKER DO
Other - Org Name:PORTLAND VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:615-325-2020
Mailing Address - Street 1:PO BOX 470
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-0470
Mailing Address - Country:US
Mailing Address - Phone:615-325-2020
Mailing Address - Fax:615-325-5862
Practice Address - Street 1:605 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1619
Practice Address - Country:US
Practice Address - Phone:615-325-2020
Practice Address - Fax:615-325-5862
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DONALD W BLOCKER OD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-05
Last Update Date:2014-10-24
Deactivation Date:2007-09-25
Deactivation Code:
Reactivation Date:2008-03-04
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3595433Medicare PIN
TN0728430001Medicare NSC