Healthcare Provider Details

I. General information

NPI: 1891885380
Provider Name (Legal Business Name): DOUGLAS P BLACKALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 NE GLISAN ST
PORTLAND OR
97213-2933
US

IV. Provider business mailing address

PO BOX 3395
PORTLAND OR
97208-3395
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-6096
  • Fax:
Mailing address:
  • Phone: 503-215-6023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License NumberMD202871
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License NumberC-7459
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberC-7459
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberMD202871
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: