Provider Demographics
NPI:1992809966
Name:BLANK, BRUCE HENRY (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:HENRY
Last Name:BLANK
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 1:164 NW MACLEAY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3323
Mailing Address - Country:US
Mailing Address - Phone:503-228-1253
Mailing Address - Fax:503-228-1797
Practice Address - Street 1:164 NW MACLEAY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3323
Practice Address - Country:US
Practice Address - Phone:503-228-1253
Practice Address - Fax:503-228-1797
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09769208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology