Healthcare Provider Details

I. General information

NPI: 1770826372
Provider Name (Legal Business Name): BRIAN MATTHEW BLAIR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST STE 103
GRESHAM OR
97030
US

IV. Provider business mailing address

541 NE 20TH AVE STE 225
PORTLAND OR
97232-2895
US

V. Phone/Fax

Practice location:
  • Phone: 503-935-8088
  • Fax:
Mailing address:
  • Phone: 503-963-2801
  • Fax: 503-963-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD191957
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: