Provider Demographics
NPI:1831342773
Name:ONGKEKO, EDUARDO ERASTO SANTIAGO (MD)
Entity type:Individual
Prefix:
First Name:EDUARDO ERASTO
Middle Name:SANTIAGO
Last Name:ONGKEKO
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:541-266-4565
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:541-266-4565
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT192364207Q00000X
ORMD154449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR161133OtherNBMC-MAIN GROUP MEDICAID
OR500635456Medicaid
OR1407812365OtherNBMC-MAIN GROUP NPI
OR93-0635514OtherNBMC-MAIN GROUP TAX ID FOR BILLING
ORR0000WFBTVOtherNBMC-MAIN GROUP MEDICARE