Provider Demographics
NPI:1598761959
Name:GANGAN, CELSO A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CELSO
Middle Name:A
Last Name:GANGAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1245 NW 4TH ST
Mailing Address - Street 2:STE 201
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1680
Mailing Address - Country:US
Mailing Address - Phone:541-323-4545
Mailing Address - Fax:541-323-4546
Practice Address - Street 1:1245 NW 4TH ST
Practice Address - Street 2:STE 201
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1680
Practice Address - Country:US
Practice Address - Phone:541-323-4545
Practice Address - Fax:541-323-4546
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD23086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287491Medicaid
OR114525Medicare ID - Type Unspecified
OR287491Medicaid