Provider Demographics
NPI:1912923152
Name:NONWEILER, BLAKE A (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:A
Last Name:NONWEILER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1650 NW NAITO PKWY
Mailing Address - Street 2:STE 185
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2535
Mailing Address - Country:US
Mailing Address - Phone:503-525-7690
Mailing Address - Fax:503-525-7652
Practice Address - Street 1:2200 NE NEFF RD STE 200
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4281
Practice Address - Country:US
Practice Address - Phone:541-382-3344
Practice Address - Fax:541-322-2286
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD19775207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR077537Medicaid
OR077537Medicaid
OR133318Medicare ID - Type Unspecified