Provider Demographics
NPI:1871574640
Name:BLENNING, CAROL ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ELIZABETH
Last Name:BLENNING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 NW SAVIER ST.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1773
Mailing Address - Country:US
Mailing Address - Phone:503-494-8417
Mailing Address - Fax:503-346-8021
Practice Address - Street 1:3930 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1643
Practice Address - Country:US
Practice Address - Phone:503-418-3900
Practice Address - Fax:503-418-3939
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR81880Medicaid
E92508Medicare UPIN