Provider Demographics
NPI:1457325060
Name:CELEBOGLU, CANER R (MD,FACS)
Entity Type:Individual
Prefix:MR
First Name:CANER
Middle Name:R
Last Name:CELEBOGLU
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SIXTH ST
Mailing Address - Street 2:PO BOX 828
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364
Mailing Address - Country:US
Mailing Address - Phone:815-673-5533
Mailing Address - Fax:815-673-2554
Practice Address - Street 1:104 SIXTH ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364
Practice Address - Country:US
Practice Address - Phone:815-673-5533
Practice Address - Fax:815-673-2554
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058159208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058159Medicaid
IL036058159Medicaid
607330Medicare PIN