MEDICARE: RICHARD A. GANGNES M.D. INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2082S0099X	Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician	G30030	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ00859Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1568495562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD A. GANGNES M.D. INC.

Provider Business Mailing Address
First Line	:	665 CAMINO DE LOS MARES STE 100
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-2840
Country	:	US
Telephone Number	:	949-276-4141
Fax Number	:	949-496-2705

Provider Business Practice Location Address
First Line	:	665 CAMINO DE LOS MARES STE 100
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-2840
Country	:	US
Telephone Number	:	949-276-4141
Fax Number	:	949-496-2705

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. CHRIS GANGNES
Credential	:
Telephone Number	:	949-276-4141

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	05/05/2010

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