Provider Demographics
NPI:1588756134
Name:VALENTINE, BLAIR O (MD)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:O
Last Name:VALENTINE
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5133
Practice Address - Country:US
Practice Address - Phone:360-493-4083
Practice Address - Fax:360-486-6436
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G77837Medicare UPIN
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
ILL89396Medicare ID - Type UnspecifiedINDIVIDUAL #
IL833120Medicare ID - Type UnspecifiedGROUP #