Provider Demographics
NPI:1235490038
Name:CORCORAN, BLAKE COOPER (MD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:COOPER
Last Name:CORCORAN
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 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:675 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2875
Practice Address - Country:US
Practice Address - Phone:541-451-6282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60771757207QS0010X
ORMD222671207QS0010X
PAMD458625207Q00000X, 207QS0010X
WAMD600771757207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine