Healthcare Provider Details

I. General information

NPI: 1487567350
Provider Name (Legal Business Name): BLAKE O'CONNOR MED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ALPINE AVE
BOULDER CO
80304-3401
US

IV. Provider business mailing address

1029 N PENNSYLVANIA ST APT 3W
DENVER CO
80203-3240
US

V. Phone/Fax

Practice location:
  • Phone: 303-268-5938
  • Fax:
Mailing address:
  • Phone: 303-268-5938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: