Provider Demographics
NPI:1023377736
Name:KOGAN, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:KOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1418 CROSS ST BLDG 2
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2988
Mailing Address - Country:US
Mailing Address - Phone:618-463-7174
Mailing Address - Fax:833-974-3006
Practice Address - Street 1:1418 CROSS ST BLDG 2
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2988
Practice Address - Country:US
Practice Address - Phone:618-463-7174
Practice Address - Fax:833-974-3006
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101264911208800000X
OH35.138581208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology