Provider Demographics
NPI:1023087525
Name:BLAIR, KEVIN DEAN (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DEAN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 HERITAGE WAY SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-8600
Mailing Address - Country:US
Mailing Address - Phone:541-926-6077
Mailing Address - Fax:541-926-0605
Practice Address - Street 1:2330 HERITAGE WAY SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-8600
Practice Address - Country:US
Practice Address - Phone:541-926-6077
Practice Address - Fax:541-926-0605
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2396AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116850Medicaid
ORMB114153OtherDEA DRUG NUMBER
ORR00WCKKFFMedicare PIN
ORU41603Medicare UPIN
OR116850Medicaid
OR139548Medicare PIN