Provider Demographics
NPI:1396774014
Name:CEBALLOS, CARLOS (MD)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:CEBALLOS
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:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-0053
Mailing Address - Country:US
Mailing Address - Phone:503-650-4359
Mailing Address - Fax:503-650-6913
Practice Address - Street 1:10300 NE HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-650-4359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12612207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Not Answered208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR225094Medicaid
OR225094Medicaid
A33727Medicare UPIN