Provider Demographics
NPI:1447360359
Name:GONZALES-BAGDON, CALLE A (MD)
Entity type:Individual
Prefix:
First Name:CALLE
Middle Name:A
Last Name:GONZALES-BAGDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CALLE
Other - Middle Name:ANN
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-793-9715
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:801 E WHEELER RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1820
Practice Address - Country:US
Practice Address - Phone:509-765-5606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-103519208000000X
CAG-71741208000000X
NH16068208000000X, 2080N0001X, 2080P0203X
HIMD113722080P0203X
WAMD610928942080P0203X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2168392Medicaid
AKMD34321Medicaid
AK8EZ57FMedicare ID - Type Unspecified
AKMD34321Medicaid