Basic Information
| Provider Information | |||||||||
| NPI: | 1396774014 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CEBALLOS | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53 | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970270053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036504359 | ||||||||
| FaxNumber: | 5036506913 | ||||||||
| Practice Location | |||||||||
| Address1: | 10300 NE HANCOCK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036504359 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD12612 | OR | X | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0000X | MD12612 | OR | X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 225094 | 05 | OR | MEDICAID |