Basic Information
| Provider Information | |||||||||
| NPI: | 1831342773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ONGKEKO | ||||||||
| FirstName: | EDUARDO ERASTO | ||||||||
| MiddleName: | SANTIAGO | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664565 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 07/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MT192364 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD154449 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 161133 | 01 | OR | NBMC-MAIN GROUP MEDICAID | OTHER | 500635456 | 05 | OR | MEDICAID | 1407812365 | 01 | OR | NBMC-MAIN GROUP NPI | OTHER | 93-0635514 | 01 | OR | NBMC-MAIN GROUP TAX ID FOR BILLING | OTHER | R0000WFBTV | 01 | OR | NBMC-MAIN GROUP MEDICARE | OTHER |