Provider Demographics
NPI:1770826372
Name:BLAIR, BRIAN MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MATTHEW
Last Name:BLAIR
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 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:24900 SE STARK ST STE 103
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-935-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD191957208800000X, 208800000X
PAMT204533208800000X
CAA154848208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500760980Medicaid