Provider Demographics
NPI:1760555759
Name:GAOGHAGAN, JILL B (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:B
Last Name:GAOGHAGAN
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 1:2840 LONG BEACH BLVD
Mailing Address - Street 2:315
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1516
Mailing Address - Country:US
Mailing Address - Phone:562-595-5479
Mailing Address - Fax:562-989-2911
Practice Address - Street 1:2840 LONG BEACH BLVD
Practice Address - Street 2:315
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1516
Practice Address - Country:US
Practice Address - Phone:562-595-5479
Practice Address - Fax:562-989-2911
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG70797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G707970Medicaid