Provider Demographics
NPI:1770745309
Name:BLATZ, BRICE WILLIAM (MD, MS)
Entity type:Individual
Prefix:
First Name:BRICE
Middle Name:WILLIAM
Last Name:BLATZ
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 SW NIMBUS AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7591
Mailing Address - Country:US
Mailing Address - Phone:503-217-6305
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2543
Practice Address - Country:US
Practice Address - Phone:616-391-1405
Practice Address - Fax:616-391-8611
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL2132390200000X
MI4301092779208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVLL2132OtherREG. MEDICAL LIC.