Provider Demographics
NPI:1720216963
Name:ONGOLE, BHASKAR (MD)
Entity Type:Individual
Prefix:
First Name:BHASKAR
Middle Name:
Last Name:ONGOLE
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4501
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA240789207R00000X
ORMD158190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WFBTVOtherGROUP MEDICARE NORTH BEND MEDICAL CENTER
OR500664151Medicaid
OR93-0635514OtherGROUP TAX FOR BILLING NORTH BEND MEDICAL CENTER
OR1407812365OtherGROUP NPI NORTH BEND MEDICAL CENTER
OR161133OtherGROUP MEDICAID NORTH BEND MEDICAL CENTER
OR500664151Medicaid