Provider Demographics
NPI:1174937619
Name:POWELL, BLAKE GORDON (OD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:GORDON
Last Name:POWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3975 NAVARRE AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3437
Mailing Address - Country:US
Mailing Address - Phone:419-698-4949
Mailing Address - Fax:419-698-9948
Practice Address - Street 1:3975 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3437
Practice Address - Country:US
Practice Address - Phone:419-698-4949
Practice Address - Fax:419-698-9948
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6309152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist