Provider Demographics
NPI:1982645370
Name:LONSBERRY, BLAIR BURTON (MS, OD, MED)
Entity Type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:BURTON
Last Name:LONSBERRY
Suffix:
Gender:M
Credentials:MS, OD, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 NW WALMER DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-4252
Mailing Address - Country:US
Mailing Address - Phone:503-292-5348
Mailing Address - Fax:
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-352-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3149ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U68026Medicare UPIN