Provider Demographics
NPI:1962450601
Name:BLAKE, CHRISTOPHER A (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:A
Last Name:BLAKE
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 1:355 SE BAKER ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6039
Mailing Address - Country:US
Mailing Address - Phone:503-472-0423
Mailing Address - Fax:503-472-4325
Practice Address - Street 1:355 SE BAKER ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6039
Practice Address - Country:US
Practice Address - Phone:503-472-0423
Practice Address - Fax:503-472-4325
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10783207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228452Medicaid
930805004OtherTAX ID
OR200001052OtherRAILROAD MEDICARE
OR200001052OtherRAILROAD MEDICARE
C94265Medicare UPIN
OR228452Medicaid