Basic Information
| Provider Information | |||||||||
| NPI: | 1083684773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANKEN | ||||||||
| FirstName: | CELESTE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664589 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4868 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO165427 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 93-0635514 | 01 | OR | GROUP TAX FOR BILLING NORTH BEND MEDICAL CENTER | OTHER | 1407812365 | 01 | OR | GROUP NPI NORTH BEND MEDICAL CENTER | OTHER | DO165427 | 01 | OR | OREGON MEDICAL BOARD | OTHER | R0000WFBTV | 01 | OR | GROUP MEDICARE NORTH BEND MEDICAL CENTER | OTHER | 16113 | 01 | OR | GROUP MEDICAID NORTH BEND MEDICAL CENTER | OTHER | 500671822 | 05 | OR | MEDICAID |