Basic Information
| Provider Information | |||||||||
| NPI: | 1740346956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHAEL O'GARA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1215 | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974441215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412476628 | ||||||||
| FaxNumber: | 5412476629 | ||||||||
| Practice Location | |||||||||
| Address1: | 94125 4TH ST | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974441215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412476628 | ||||||||
| FaxNumber: | 5412476629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | O'GARA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5412476628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 08605 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 278506 | 05 | OR | MEDICAID |