Provider Demographics
NPI:1063074789
Name:MCCONNELL, BLAKE (MD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13129
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-1129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2485 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2151
Practice Address - Country:US
Practice Address - Phone:503-363-8047
Practice Address - Fax:503-363-6571
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12439658-1205207Q00000X
ORMD215853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine