Provider Demographics
NPI:1609821594
Name:TOLBY, BLAINE E (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:E
Last Name:TOLBY
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 1:971 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2503
Mailing Address - Country:US
Mailing Address - Phone:360-577-1771
Mailing Address - Fax:360-423-1405
Practice Address - Street 1:971 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2503
Practice Address - Country:US
Practice Address - Phone:360-577-1771
Practice Address - Fax:360-423-1405
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000020545208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8485906Medicaid